Download Section 1 - NHS Networks

Y
O
R
K
Health Economics
C O N S O R T I U M
DEPARTMENT OF HEALTH
Cross Border Healthcare and Patient
Mobility: Data and Evidence Gathering
Final Report
KARIN LOWSON, Project Director, YHEC
JAMES MAHON, Senior Associate Consultant
DIANNE WRIGHT, Research Assistant
PAULA LOWSON, Associate Consultant
SOPHI TATLOCK, Research Assistant
STEVEN DUFFY, Research Consultant
AUGUST 2010
YHEC
University of York, Market Square, Vanbrugh Way, Heslington, York YO10 5NH
Tel: 01904 433620 Fax: 01904 433628 Email: [email protected] http://www.yhec.co.uk
York Health Economics Consortium is a Limited Company
Registered in England and Wales No. 4144762 Registered office as above.
Contents
Page No.
Executive Summary
Acknowledgements
Section 1:
Introduction
1.1
Background to Study
1.2
Processes For Receipt of Health Care Abroad
1.3
Planned Healthcare
1.4
Current Evidence of Mobility
1.5
The Study
1.6
The Study Report
Section 2:
Literature review
2.1
Introduction and Methodology
2.2
Policy and Legal issues
2.3
Data on Cross Border Healthcare in the EU
2.4
Patient Choice
2.5
Planned Healthcare Initiatives
2.6
Medical Tourism
1
1
1
3
4
4
5
7
7
8
9
10
11
12
Section 3:
Collection of Data on Patients Receiving Planned Treatment Abroad
Funded by the NHS
14
3.1
Introduction
14
3.2
Analysis of E112 Data
15
3.3
Findings For E112 Analysis
15
3.4
Analysis of EHIC Claims
19
3.5
Analysis of Article 56 Data
19
Section 4:
Analysis of the Public Survey
4.1
Methodology
4.2
FIndings
4.3
Summary and discussion
4.4
Comparison of Survey Findings with Flashbarometer Findings
20
20
23
30
33
Section 5:
Focus Groups with members of the general public
5.1
Introduction
5.2
Process for Recruitment and Management
5.3
Analysis of Participants
5.4
Topics for Discussion
5.5
Findings
35
36
36
37
39
40
Section 6:
Survey of NHS Commissioners
49
6.1
Introduction
50
6.2
Analysis of Responses
51
6.3
Analysis of Data on Patients Who Have Received Treatment Abroad in Mainland
Europe
55
Section 7:
Case studies of NHS
7.1
Introduction
7.2
Patient Numbers
7.3
Information, Knowledge and Advice
59
60
60
61
7.4
7.5
7.6
Processes For Considering Planned Treatment Abroad
Barriers To Funding Patients Abroad
Northern Ireland
62
64
67
Section 8:
Mystery Shopping with NHS Commissioners
8.1
Introduction
8.2
Methodology
8.3
Findings
69
70
70
71
Section 9:
Survey of Professional Organisations and Patient Associations
9.1
Introduction
9.2
Analysis of Responses
75
75
76
Section 10: Conclusions and Recommendations
10.1
Demand
10.2
Processes
79
80
81
Bibliography
Appendices:
Appendix A
Detailed Costs of E112s
Executive Summary
1.
INTRODUCTION
In July, 2008, the European Commission (EC) published a draft Directive on the application
of patients' rights in cross-border healthcare, which sought to codify existing ECJ case law
on patients' rights and clarify their application. This issue had previously been subject to
public consultation by the EC to which the Department of Health (DH) had responded.
The Department of Health (DH) commissioned a targeted research and information
gathering study to collect information on public and patient knowledge, attitudes and
preferences with regard to the proposed EU Cross-Border Healthcare Directive (EUCBHD),
and on patient mobility issues in general. The study had two broad objectives:

To develop an understanding of the public’s and/or patients’ responses to the
Directive, including an assessment of the likely numbers choosing to travel;

To assess the state of NHS readiness, including a review of current processes and
numbers being managed.
Activities undertaken to address these objectives comprised the collection of data from the
Department for Work and Pensions (DWP); a large survey and focus groups with members
of the public; a survey of, case studies with and mystery shopping of NHS commissioners;
and a survey of professional organisations and patient associations. The whole study was
underpinned by a literature review and stakeholder interviews It is also believed that patients
are increasingly confident about their rights, options and entitlements about their NHS
healthcare. Following a number of high profie legal rulings in Europe, many of these rights
and entitlements now extend to healthcare accessed in other European countries, as
confirmed in the NHS Constitution. Part of the research study investigated how widely
people were of their rights in respect of cross border healthcare.
2.
UNDERSTANDING PUBLIC AND PATIENTS’ ATTITUDES
According to the public survey, 62% stated they would consider seeking planned healthcare
abroad in the future with 50% citing avoidance of long waiting lists as the main advantages
to going abroad. These findings are reinforced by the findings from the focus groups, where
waiting times were a driver to seek healthcare abroad. Disadvantages cited included not
having family nearby, not being to speak the language and the costs of travelling.
While we cannot provide strong evidence on the scale of any future demand for planned
treatment in the EU, the evidence found does suggest that there is a willingness to consider
going abroad in a majority of the population – although many indicated they did not know
where to go for information if they were considering overseas treatment.
3.
ASSESSMENT OF LIKELY NUMBERS CHOOSING TO TRAVEL
To the year ending 13 November 2009 there were 747 E112s issued by the DWP. 108 of
these were non-maternity relating to 64 patients, 47 of whom were British. We estimate the
costs of these 108 E112s to be no more than £1.1million or £17,000 per E112. As there
were low numbers of E112s issued, it can be deduced that the majority of PCTs did not
agree to fund planned healthcare abroad using an E112 in the 12 months analysed.
i
Taking evidence from the survey, the lack of translation of potential into current demand for
overseas treatment could be that supply of healthcare in the UK meets current demand and
so people do not need to go overseas. However, given the change in emphasis away from
targets around waiting times, increases in waiting times or size of waiting lists may lead to an
imbalance in supply and demand and more patients may seek treatment abroad. The new
Directive may also increase the demand for overseas treatment amongst people with no
intrinsic barrier to treatment outside the UK, perhaps for routine treatment such as dentistry
although we found no evidence of this.
Consistent messages from across all EU countries are that whilst many might consider
travelling outside their country to receive healthcare, neither our survey, nor the EU survey,
suggest that this consideration will necessarily be translated into demand or that the
numbers are likely to increase under current supply of healthcare, such as the management
of waiting lists. This may change in the future.
4.
ASSESSMENT OF NHS READINESS
There is limited evidence that preparations are being made for the introduction of the new
directive and strong evidence that many local commissioners are not even aware that a new
directive is coming. Whilst the commissioners’ survey found that many PCTs and Health
Boards stated that they were looking at future demand for overseas care, this was not found
in the case studies. The current system of using panels to assess a request is, in our
opinion, unsuitable should numbers increase with the introduction of the new directive which our research has not discounted.
The clear, consistent message throughout the research is that the concept of patient mobility
and the correct application of patients’ extended rights are areas that PCTs find complex and
challenging. This has contributed to some PCTs applying criteria by which they make
decisions to fund that do not seem to have any basis in current legislation or case law. The
NHS is therefore at considerable risk of challenge.
The majority, if not all, PCTs see overseas treatment within the EU as being a low priority
area. Knowledge of processes and criteria for NHS funding of treatment abroad does not
appear widely known by staff within individual PCTs. Further, the mystery shopping
indicated that PCTs do not have the processes or knowledge to deal with queries, and may
not be offering helpful or accurate advice.
If anything, the national picture is likely to be much worse than was found through our
evidence gathering as it is likely that those PCTs that did choose to engage with the
research are areas that do attempt to give this subject some priority. Our strong suspicion is
that those PCTs that failed to engage (the vast majority of PCTs) treat this as a very low
priority area – with no one locally who is responsible to assess requests or offer correct
advice.
Our research shows that commissioners are applying criteria in deciding on whether to fund
overseas treatment that appears to run counter to case law. This, coupled with the apparent
lack of interest in this area from local commissioners and the potential consequences of
failing to allow someone treatment abroad when they had a clear right for funding under
ii
legislation and case law, means in our opinion this is a responsibility that would be more
appropriately handled nationally.
This recommendation holds if numbers stay low or increase with the new Directive. With low
numbers it seems an inefficient use of resources to make each local commissioner have
their own set of processes to decide on requests. If numbers increase, a higher likelihood is
created that a decision will be challenged and given current local practice the decision found
to be in contradiction of legislation and case law.
iii
Acknowledgements
We would like to thank all those working in the NHS and in professional organisations and
patients’ associations who completed our surveys, as well as those PCTs who participated in
our case studies and mystery shopping.
We are extremely grateful to everyone in the Department of Work and Pensions, Overseas
Healthcare Division, especially Judith Pharoah and her team who assisted us with our
collection and analysis of data on E112s.
We would like to thank Adrea Begley at DHSSPS for providing the data on E112s for
Northern Ireland.
We are also grateful to Magda Rosenmoller from IESE Business School at the University of
Navarra and Neil Lunt from York Management School at the University of York, who gave
advice and offered material to the study, including work that they had undertaken, and to
Keith Pollard from Treatment Abroad, who offered useful information and advice and who
generously allowed us to use their Survey.
Finally, we would like to thank the team at the Department of Health, including Rob Dickman,
Paul Whitbourn, Mark Wilson and Amy Everton, who commissioned the study, and who
offered useful advice and comments throughout the project life.
Section 1:
1.1
Introduction
BACKGROUND TO STUDY
Whilst most people receive their health care in the country in which they reside, patients may
travel to other countries to receive healthcare. However, evidence suggests that the number
of people who obtain care in another country is low, accounting for around 1% of total health
care expenditure. Rules for receiving cross-border healthcare and for the reimbursement of
costs are not always clear, although case law has been established by the European Court
of Justice (ECJ). In July, 2008, the European Commission (EC) published a draft Directive
on the application of patients' rights in cross-border healthcare, which sought to codify
existing ECJ case law on patients' rights and clarify their application. This issue had
previously been subject to public consultation by the EC to which the Department of Health
(DH) had responded.
The DH carried out consultation on the proposed Directive in the autumn of 2008. The
purpose of this consultation was to help inform the UK Government’s negotiating position on
the draft Directive and begin data collection to aid assessment of the impact that the
proposed Directive could have on the UK.
It is also believed that patients are increasingly confident about their rights, options and
entitlements about their NHS healthcare, following a number of high profile legal rulings in
Europe, many of these rights and entitlements now extend to healthcare accessed in other
European countries, as confirmed in the NHS Constitution. Part of the research study
investigated how widely people were of their rights in respect of cross border healthcare.
Against this backdrop, the DH commissioned a targeted research and information gathering
study to collect information on public and patient knowledge, attitudes and preferences with
regard to the proposed EU Cross-Border Healthcare Directive (EUCBHD), and on patient
mobility issues in general.
1.2
PROCESSES FOR RECEIPT OF HEALTH CARE ABROAD
1.2.1
Overview of patient mobility
Legido –Quigley1 and her colleagues devised a useful typology to describe patient mobility,
summarised in Box 1, and believe that the data available seriously underestimates the
numbers seeking these routes.
1
Legido-Quigley H et al (2007). Patient mobility in the European Union. BMJ: 334, 188-190
Section 1
1
Box 1.1
Broad categories of patient mobility
Category
Temporary visitors abroad
People retiring to other countries
People in border regions
People sent abroad by their home systems
People going abroad on their own initiative
Of particular interest are those in the latter two categories. Examples of schemes in which
people are sent abroad by their system include a pilot project established by the DH in 2001,
under which patients from the south-east and south-west received care in French and
German hospitals for orthopaedic and ophthalmic conditions, evaluated by YHEC2; the
Norwegian Medical Treatment Abroad project which was used to reduce waiting lists for
elective surgery; and longer term schemes under which small countries lacking specialised
treatment options send patients abroad.
Rosenmoller, under the Europe4patients work, has developed a useful patient mobility
typology, examining the relationship between types of patient flows, and types of
arrangements, as shown in figure 1.
Figure 1
Typology of patient mobility3
Types of arrangements
Types of patient flows
Reg 1408/71
Abroad when
in need of
care
Going abroad
for care
1.2.2
Institutionally
arranged
care
Self managed
care
Short term
Double residence
Long-term
Familiarity
Availability
Financial costs
Perceived quality
(bio)ethical legislation
Healthcare Tourism
The number of patients seeking treatment abroad under their own initiative appears to have
increased reflecting ‘healthcare tourism’. Examples include receipt of dental care from
Hungary, and surgery in South Africa. Intermediary companies exist which assist patients in
choosing health care organisations, and arranging their care. Under this category are
patients seeking treatment which may not be available in their home country, for example
abortions, or fertility treatment.
2
3
Lowson K, O’Reilly J ( 2002) Evaluation of Treating Patients Overseas. Report for DH
Rosenmoller M (2007): Patients on the Move in Europe. Presentation to EP-IMCO Hearing.
Section 1
2
1.3
PLANNED HEALTHCARE
Before August 2001, English purchasers were not allowed to contract with hospitals in other
European countries for treatment of NHS patients. Individual patients could apply for
authorisation to be treated abroad (form E112), but this was a difficult process. For example,
in 2000, only 1,100 patients obtained authorisation for overseas treatment.
There are currently two parallel routes under which patients can obtain and receive payment
for planned treatment from NHS Commissioners. (Unplanned treatment is covered by the
European Health Insurance Card). There are subtle differences between the two schemes.
Article 22 of Regulation 1408/71
This scheme is based on agreements between governments, and there is no limit to how
much will be paid, even if treatment costs more than in the NHS. The amount paid matches
the treating country’s contribution. The E112 form entitles patients to treatment in the statefunded sector in another EU country and Switzerland. Treatment is provided under the
same conditions of care and payment as residents of that country. Therefore in systems
where patients incur co-payments, patients from other countries selecting health care in
these countries may also be liable for the same co-payment, (dependent on whether the
actual cost of care as paid by the NHS is lower than the costs incurred in the NHS).
Article 56
Under this scheme, a patient is treated as if they are a member of the home country. A
financial contribution can be made for private or state-provided treatment, thus potentially
widening the scheme. Patients have to pay for the total costs of treatment, and be reimbursed after completion. The maximum amount that can be claimed is assessed by a
local NHS commissioner, which cannot be more than the patient incurred on treatment, and
which restricts the costs to those incurred under the NHS.
Commissioners have been issued with comprehensive guidance on patient mobility and on
E112 application processes, including a flow chart for assessing a request by a patient to
receive treatment abroad. The guidance also lays out the principles, which if followed, allow
commissioners to meet the EU requirements.
The ECJ has previously criticised the NHS for not having clear criteria for managing prior
authorisation systems. Of concern still, is that commissioners are not clear about the
implications of patients seeking reimbursement under either route. Due to the differing reimbursement mechanisms, one route may be more cost effective than the other, dependent
on the treatment being sought. On average, re-imbursement under the article 56 route may
be more cost effective for PCTs than under the E112 route, as the administrative process
may be less complex, and the costs to PCTs no higher than if they commissioned the
services from an NHS provider in the UK.
Section 1
3
1.4
CURRENT EVIDENCE OF MOBILITY
Evidence has been collected on a variety of projects and case studies across Europe4, for
example through the Europe for Patients project, the objective of which is to contribute
scientific evidence that will enable policy makers at EU and national levels to take concerted
and coordinated actions to enable patients to benefit from enhanced mobility. It is believed
that increased mobility offers benefits but comes with challenges.
There is limited information on the number of people who travel abroad from the UK for
health related reasons. Based on data collected from the International Passenger Survey, it
is estimated that around 50,000 people travel to Europe for “health reasons”. This estimate
may be inaccurate due to the small sample size of those giving this reason, and the
interpretation by respondents of the term “for health reasons”. The number of people
receiving treatment under E112 is also believed to be small, with an estimate of around 550
in 2007. No data appears to be available for those using the article 56 route, although the
number is believed to be very small in the UK.
Evidence5 from research on overseas patients schemes, suggests that few people would be
willing to travel overseas for treatment. The DH, in their Impact Assessment of the EUCBHD
calculated the total notional cost of travel as £770, and hence, for people to travel, they must
perceive the benefit from the overseas treatment to be at least £770 higher than the benefit
from NHS treatment. This relatively high cost thus supports the evidence that low numbers
of patients seek treatment overseas and would in the future.
Evidence from the London Patient Choice scheme confirms this view, in which around 1,000
patients chose treatment abroad, to be paid for by the NHS. These were mostly orthopaedic
patients waiting longer than six months, and were a small percentage of the total number of
people who had been waiting for treatment. Most research on Choice Initiatives, including a
study undertaken by YHEC into choices exercised by patients requiring ophthalmic
treatment in a PCT in North Yorkshire, finds that the majority of patients prefer to be treated
nearer their own home. Unfortunately, the study undertaken by YHEC for the DH on
patients travelling overseas could not examine uptake, as commissioners did not collect the
data on offers made and refusals. However the study was able to examine processes and
patient satisfaction.
Thus, in summary, the evidence from research to date indicates variable success in the UK,
with small numbers of patients availing themselves of treatment overseas, probably for a
variety of reasons. Shorter waiting times, combined with active local patient choice options
may now contribute to an even smaller number wishing to use this route.
1.5
THE STUDY
The study had two broad objectives:
4
5
Rosenmoller M et al (2006) Patient Mobility in the European Union. www.Europe4patients.org
See Department of Health (2008) Impact Assessment of European Commission’s proposal for legislation on
patients’ rights in cross-border health care.
Section 1
4

To develop an understanding of the public’s and/or patients’ responses to the
Directive, including an assessment of the likely numbers choosing to travel;
To assess the state of NHS readiness, including a review of current processes and
numbers being managed.

To address these objectives, YHEC undertook eight activities, several of which were
undertaken in parallel, and several of which addressed more than one objective. The
objectives and activities are summarised in table 1.1.
Table 1.1
Summary of study objectives and activities
Objectives of study
Understanding
public/patient
attitudes
Assessment of
likely numbers
choosing to travel
Collection of data from DWP
Public survey

√
√
√
Focus Groups with public
Survey of NHS commissioners
√
√
√
√
Case studies with NHS
commissioners
Mystery Shopping
√
√
√
Survey of professional organisations
and patient associations
Literature review and stakeholder
interviews
√
√
√
√
Study activities
1.6
Assessment of
NHS readiness
√
√
THE STUDY REPORT
The DH requested that a report be written following completion of the study, which
comprises evidence and recommendations on:






Patient/public perceptions and motivations;
The likely number of people who will travel;
The state of play on the quality, timeliness and accuracy of NHS responses to
cross-border healthcare requests;
Whether the NHS requires additional support from the DH, and what that support
might be;
How the collection of data on cross-border healthcare might be established on a
sounder basis in the future
Areas that warrant further investigation.
This report discusses in subsequent sections:

Section 2, the literature review and stakeholder interviews
Section 1
5








Section 3, collection of data on patients that have received planned healthcare
abroad with public funding
Section 4, the public survey
Section 5, focus groups with the public
Section 6, the survey of NHS commissioners
Section 7, case studies with NHS commissioners
Section 8, mystery shopping, contacting NHS commissioners
Section 9, the survey of professional organisations and patient associations
Section 10, emergent themes and recommendations
A technical appendix is also available, providing all survey tools used, and the literature
search strategy.
Section 1
6
Section 2:
Literature review
Key findings
 Whilst some of the literature reviewed looked at cross border issues in mainland
Europe and in the US, the findings across all literature reviewed are remarkably
similar, and the hypotheses raised are those tested in the study;
 There is an acknowledged lack of data on how many people receive healthcare
outside their country of residence: therefore this study which has collected
detailed evidence provides valuable evidence for the DH;
 Whilst patients are able to exercise choice on where treatment is received, most
evidence suggests that they prefer to be treated closer to home. Factors which
might contribute to travelling abroad for healthcare include waiting times and
lower quality of care;
 Planned healthcare initiatives, whereby patients received healthcare abroad,
under an NHS managed scheme, had limited success. Whilst patients were
happy with treatment received, healthcare professionals had concerns. These
initiatives are not a feature of current policy;
 The number of patients who travel abroad for healthcare for which they pay are
still relatively low. These people are mostly seeking lower cost alternatives to
private healthcare in the UK, and treatment received is normally not available on
the NHS. The exception to this is dental care, for which there is a demand.
However, the majority of those being treated abroad, are likely to pay for this
treatment in the UK;

2.1
These broad findings were reflected in the study, especially in the public survey
and focus groups, whereby factors influencing travel abroad were tested.
INTRODUCTION AND METHODOLOGY
The purpose of the literature review was to inform the study, the methodologies and the
survey tools, as well as serving as an update for the DH on reviews, research studies, data
collected, and commentaries on a range of topics of relevance to cross border healthcare.
An extensive literature search was undertaken, the methodology for which, including search
terms, is shown as appendix A in the supporting technical report. Following de-duplication,
111 potentially relevant articles were identified, out of which 38 were selected for inclusion.
The project budget did not include provision for an in-depth literature review; therefore
articles were mostly excluded on the basis of title, although many were excluded on the
basis of abstracts. The literature search was supplemented by a review of grey literature,
including publications from EU websites including the European Commission, Europe for
Patients, workshops and conference presentations. Stakeholder interviews also identified
Section 2
7
useful publications and sources of information. Two strands of literature yielding significant
numbers of articles were ‘medical tourism’; and cross border healthcare in mainland Europe.
Only the most relevant literature on these topics was examined. The full bibliography of
literature included in the review is provided at the end of this report.
Additionally, an extensive literature review6 on cross-border patient mobility in the EU
published in 2006 was reviewed. Given the extensive nature of this review, the authors of
this report chose not to replicate the work already undertaken, but have summarised the
review’s findings. The scope of this review by Glinos and Baeten was defined as “covering
concrete examples”; therefore they did not look at policy documents but at studies of
initiatives.
Whilst most literature reviewed is in the context of healthcare delivered within a local health
care system, the issue of medical tourism addresses patients travelling outside their
healthcare system with payment made by themselves, or their or employers’ insurance.
The findings have been summarised under the following themes:
 Discussion of policy and legal issues
 Data collection and surveys
 Patient choice
 Planned healthcare abroad
 Medical tourism
2.2
POLICY AND LEGAL ISSUES
There is extensive literature on policy and legal issues, including reports from the DH, such
as consultation exercises and guidance; guidance from external organisations; and legal
interpretation of case law and guidance. Additionally, many commentators have reflected on
current policy, literature and studies to develop frameworks for considering cross-border
healthcare.
The NHS European Office of the NHS Confederation, in a briefing7 published in June 2009
believed that “as the NHS develops the way it delivers healthcare to incorporate patient
choice and a wider role for independent healthcare providers and enterprises, the extent to
which NHS activity could be challenged under EU competition rules becomes less clear”.
They further assert “it will be important to monitor developments in this area, including the
advice given by the recently established NHS Cooperation and Competition Panel, and
whether this may have the consequent effect of exposing more NHS activity to challenges
under EU competition law in the future”.
6
Glinos I and Baeten R (2006). A Literature Review of Cross-Border Patient Mobility in the European Union.
Europe for Patients Project. www.europe4patients.orf
7
NHS Confederation (2009). Briefing. What do EU competition rules mean for the NHS?
www.nhsconfed.org/publications.
Section 2
8
Several articles, including an editorial, have been published in the BMJ, commenting on the
EU proposals. McKee and Belcher8 comment “the proposed legal instrument is a framework
directive. This establishes the principles underlying subsequent legislation and sets the
broad parameters within which it can operate. However, it leaves flexibility to respond to
specific problems and changing circumstances”. Watson9 summarises the draft legislation in
a more recent edition of the BMJ.
Several articles10 reviewed focused specifically on the legal aspects, and there are likely to
be many more. These have not been summarised here, but mostly served as background
information for the Evaluation Team.
Of interest to the NHS are likely to be briefings, such as that issued by the NHS
Confederation, or web sites such as that developed by the DH11.
2.3
DATA ON CROSS BORDER HEALTHCARE IN THE EU
The DH commissioned this study on cross-border healthcare, in part to address the question
of how many patients have travelled abroad for planned healthcare.
In answer to the question, “what is the scale of this social and health care phenomenon
across Europe?”, Rosenmoller12 believes that “it is important to stress that there is practically
no information about the phenomenon”. She cites a study from Germany suggesting that it
affects around 1% of patients and 1% of health spending.
In the light of the perceived limited data available on how many people receive healthcare
outside their country of residence across the EU, the Health Strategy Unit (C5) of the Health
and Consumer Protection Directorate-General (DG SANCO) commissioned a study under
the Flash Barometer framework polling citizens from all EU countries on their experiences
and expectations concerning patient mobility. More than 27,000 interviews were undertaken
in 2007, of which some 1,000 were undertaken in the UK. The study found that around 4%
of EU citizens had received medical treatment in another EU country including urgent care,
but that more than half interviewed are open to travel to another EU country. More detailed
comments on this study are discussed in section 3 of this report, comparing the study results
with those of our public survey.
Treatment Abroad, a medical tourism broker and website have conducted surveys of those
using their website. They compiled data from 132 healthcare providers in 30 countries that
promoted their services to the UK market. Their recent survey (from 2008) estimated that
around 50,000 people travelled abroad in that year, and spent around £161 million, with
8
McKee M and Belcher P (2008). Cross Border Health Care in Europe. BMJ, 337 a610.
Watson R (2009). EU strengthens requirements for patients to get prior approval before being treated abroad.
BMJ; 338 b1400
10 For example:
Sellars C (2008) Cross border access to healthcare services within the European Union. World Hospitals and
Health Services, vol 2, 1 pp24-27
Coucher S (2002) The legal framework in relation to patient mobility Common Market Law Review
11 http://www.nhs.uk/NHSEngland/Healthcareabroad/Pages/Healthcareabroad.aspx
12 Rosenmoller M quoted in article by Ros M (2009). Monograph Compartir.
9
Section 2
9
dentistry being the most popular option. They estimate that around 20,000 people from the
UK travel abroad for dental care, spending around £2,500 each.
Vallejo13 et al undertook a study the aim of which was to estimate the volume and main
diagnoses of cross-border care in eight EU countries. They combined findings from three
independent studies compiling self-reported information on admissions data from over 200
hospitals. They found that cross border admissions accounted for less than 1% of the total
admissions in the hospitals studied, which was probably an underestimate. They
acknowledged limitations of their study as a result of, for example, the inability to
independently identify cross-border patients in hospitals’ databases, low validity of
information, and uses of different coding systems. Common patient conditions included
diseases of the circulatory system (mainly acute myocardial infarction), fractures and
obstetric care.
2.4
PATIENT CHOICE
Of relevance to decisions on travelling abroad for planned healthcare, is the issue of patient
choice. There is extensive literature on patient choice, which has been reviewed elsewhere,
and we have not replicated this. We have, however, extracted the key points from an SDO14
review of the literature, and have examined the findings from a study by the Rand15
organisation for the DH. We have also extracted findings from the review by Glinos and
Baeten.
Fotaki et al found that patient choice for health care was not a high priority for NHS patients
However, there was interest in patients choosing their hospital; for example, when they
faced problems with their local providers such as long waiting times. The London Patient
Choice Pilot is an example. Fotaki et al did examine evidence from other health care
systems, and found that in health systems sharing similar features with the NHS, there is
little enthusiasm by patients in these countries to take up choice of provider.
Burge et al found that patients preferred higher quality hospitals, and GPs’ advice over which
hospital to choose, whilst being important, did not override other information, such as
hospital performance and travel times. Patients, unsurprisingly, had a preference for shorter
travel times, and for lower travel costs (irrespective of eligibility under schemes which paid
for travel costs). Certain patient characteristics were associated with loyalty (i.e. a higher
propensity to select local hospitals), including having poor health or travelling to their local
hospital by bus. Those with internet access or having a poor perception of their local hospital
were more likely to be disloyal.
13
Vallejo P et al (2009). Volume and diagnosis: an approach to cross-border care in eight European countries.
Qual. Saf. Health Care: 18; i8-i14.
14 Fotaki M et al (2005) Patient Choice and the Organisation and Delivery of Services. Report for NCCSDO by
Manchester Business School
15 Burge P et al (2006) Understanding Patients’ Choices at the Point of Referral. Report for DH by Rand
Corporation
Section 2
10
Glinos and Baeten, found that patients’ preference or willingness for cross border healthcare
could be explained under five key drivers or determinants: familiarity and proximity;
availability (quantity and type of services, for example insufficient capacity leading to
excessive waiting times, or the requirement for specialist care); financial costs (for example
where there are significant co-payments); perceived quality (due to dissatisfaction with local
systems), and bioethical legislation (in which patients will travel elsewhere for abortions or
IVF treatment).
The findings on patient choice were fed into the development of the patient survey tools.
2.5
PLANNED HEALTHCARE INITIATIVES
Four initiatives are highlighted here: three from the UK and one from Norway. All four were
undertaken against a back drop of long waiting times, and three were designed not only to
increase patient choice and reduce their waiting times, but also to be a catalyst for change in
local systems.
Lowson16 et al evaluated in a study for the DH, an initiative in the south of England across
three health economies supported by the local Regional Health Authority. An estimated 300
patients facing long waiting times for ophthalmic and orthopaedic treatment would travel to
clinics and hospitals in France and Germany. The study found that although 300 had been
planned to travel, only 190 were actually treated under the scheme. Fewer patients were
sent to Germany because contracting was more time consuming than expected, patient
selection was conservative and resources were limited. UK doctors were not cooperative,
expressing concerns over who would be responsible for complications, and lack of continuity
of care. Patients, on the other hand, mostly reported having very positive experiences,
although there were some problems with travel arrangements.
Glinos17 et al undertook a study of patients treated in Belgium from the UK, which had similar
findings. Around 600 patients were treated for hip and knee replacements, for which there
were long waiting lists. Again, although patients reported having positive experiences, some
local NHS providers showed opposition to the scheme and hindered cooperation. The
contracting process was also complex.
Evidence from the London Patient Choice Project of 2002-03 indicate that, where there are
long waiting lists, patients will go abroad for healthcare, with uptake at between 65-75%.
However, the evaluations indicated that lack of clarity in selection of patients may have
influenced uptake.
Botten18 et al reported on a project in Norway (the Patient Bridge), initiated by the Norwegian
Government, in which long waiting lists led to the sending of patients to other providers in
Europe for their healthcare. The Project was found to be relatively expensive due to
transaction and transport costs, and the relatively high treatment costs. Excessive treatment
16
Lowson K et al (2002). Evaluation of Treating Patients Overseas. Report for DH by YHEC, University of York
Glinos I et al (2005) Cross-border healthcare in Belgian hospital: An analysis of Belgian, Dutch and English
Stakeholder Perspectives. Brussels, Observatoire social europeen: 89.
18 Botten G et al (2004) Trading patient: Lessons from Scandinavia. Health Policy, 69, pp317-27
17
Section 2
11
costs were believed to be a result of insufficient cost awareness by health care purchasers.
The Project revealed large price differentials between Norwegian and other European
hospitals and within Norway, (these are not issues for current cross-border activities in the
UK). Patients were willing to participate if properly informed and supported by their local
health care workers. On the other hand, the health policy met with resistance among hospital
physicians.
Planned healthcare initiatives, such as those described above, do not seem to be a feature
of current UK healthcare policy, although possibly more common in mainland Europe and in
Ireland.
2.6
MEDICAL TOURISM
The term ‘medical tourism’ can be applied to any patient choosing to travel abroad for health
care, or more specifically to those travelling outside the financing and contracting constraints
of the local healthcare systems. Medical tourism has grown rapidly in the last 10 years,
especially for cosmetic surgery. High costs and long waiting lists in the home country, and
new technology and lower costs in destination countries, combined with reduced transport
costs and internet marketing have all contributed to this growth.
Much of the literature comes from the US, where rising costs are fuelling a movement to
outsource medical treatment. York19 gives estimates of the number of Americans travelling
outside the US for healthcare to be between 50,000 – 500,000, with charges for procedures
such as heart bypass being $11,000 in Thailand, compared to $130,000 in the US. He cites
“a new industry, medical tourism [which] has been created to advise patients on the
appropriate facility in the right country for their condition, handle all travel arrangement….”
Lunt and Carerra20 (2009) in a conference presentation, assert that the reasons for medical
tourism include costs of treatment, speed in obtaining treatment, treatment not being
available (or legal), a desire for privacy, and the ability to combine tourist attractions with
procedures. Leggat21, commenting on the particular case of dental tourism, concurs,
suggesting that it is driven by the increasing costs of dentistry, dental waiting lists and dental
workforce issues.
Of concern for all health tourists is aftercare, whether this be received by the providers of the
original healthcare (thus possibly necessitating an extended stay in the destination country),
or in the healthcare system of residence. Issues were raised in the planned cross-border
healthcare pilots discussed above. Leggat, for example, also comments that the main
difficulty with dental tourism is follow-up.
19
York D (2008). Medical Tourism: the trend toward outsourcing medical procedures to foreign countries. Journal
of Continuing Education in Health Professions. 28 (2) 99-102.
20 Lunt N and Carrera P (June 2009) Research to better understand the medical tourist industry. Conference
presentation to Health Investor Conference.
21 Leggat P (2009) Dental health, dental tourism and travellers. Travel medicine and Infectious Disease 7, 123124
Section 2
12
The role of brokers is interesting, since an issue is how individuals and/or individual
organisations determine the market, source information, and determine which providers to
choose. There are many websites dedicated to this purpose (Treatment Abroad being a
prime example), and some websites specialise in procedures, such as cosmetic surgery or
dentistry, or in particular destinations, such as Poland or Hungary. If medical tourists
themselves are paying, they can be seen as consumers, spending on a range of medical
care. Yet, consumers are normally protected in law, and of concern is obviously how to
ensure quality and safety for healthcare, and hence what are the regulatory and
accreditation frameworks around these organisations (the medical tourism brokers and the
healthcare providers).
Studies of the extent of cross border health care have indicated that the numbers of patients
are still low (around 1%), although even a doubling of this to 2% would represent a
significant number of patients. Given the apparent rise in patients taking advantage of
medical tourism, it was estimated that around 6 million Americans would seek healthcare
outside the US by 2010. This figure has been dramatically revised downwards to 1.6m.
Youngman22 comments that, in contrast to the prediction that big health insurers and
employers would send thousands of employees overseas, very small numbers of patients
have actually benefitted, although the option has been available to some employees in their
group health plans. Insurers appear to be concerned about medical liability and medical
malpractice, but more interestingly, this exploration of healthcare abroad has led to an
increasing number of hospitals within the US offering discounted packages to counter the
foreign competition. Under ‘internal’ medical tourism, patients may travel to another city
within the US to have procedures which may be up to 75% less than if treated closer to
home.
As stated earlier, medical tourism is not a significant factor for UK healthcare, although more
patients have planned healthcare under medical tourism than under E112 or article 56
routes. Treatment Abroad, a major healthcare broker and information website for potential
UK medical tourists, predicts that the number, which grew by 25% in 12 months during 2008,
will continue to grow, from the estimated 50,000 in 2007. Most treatment received is not
available on the NHS, although a significant number receive dental care. Those receiving
dental care abroad are likely to be private patients, rather than NHS patients, and even if
they were NHS patients, only a proportion of the costs would accrue to the NHS.
Nonetheless, if a proportion of these patients sought the care in the UK through NHS
dentistry, and on finding problems accessing NHS dentists and facing long waiting times for
dental care, may choose to claim for care received abroad under article 56 route. This route
does not require prior authorisation since dental care does not include inpatient care.
22
Youngman
I
(2009).
What
happened
to
those
2008
medical
tourism
forecasts?
http://www.imtjonline.com/articles/2009/what-happened-to-those-2008-medical-toursim-forecasts-30002/
Section 2
13
Section 3:
Collection of Data on Patients
Receiving Planned Treatment
Abroad Funded by the NHS
Key Points

To the year ending 13 November 2009 there were 747 E112s issued by the DWP.
108 of these were non-maternity relating to 64 patients, 47 of whom were British.
We estimate the costs of these 108 E112s to be no more than £1.1million or
£17,000 per E112

Given the low numbers of E112s issued, the majority of PCTs did not agree to fund
planned healthcare abroad using an E112 in the 12 months analysed

Only seven British people had instigated the request for planned treatment abroad.
The remainder were instigated by consultants who thought that treatment abroad
was in the best interest of their patients, usually because the treatment was
unavailable in the UK. All cases could be described as patients with conditions that
were either life threatening or significantly impacted on quality of life

The 47 non maternity E112s were issued as patients wanted treatment close to
their family, treatment with clinicians that they knew or treatment where a language
barrier would not be a problem. These reasons were also those that people
appeared to provide for seeking maternity care abroad

Over the same 12 month period there were a further 104 requests for funding for
treatment abroad that had not resulted in an E112 being issued. Of these, 32 were
requests for reimbursement of treatment already received with the remainder being
informed that they must contact their local healthcare commissioner

The DWP reported that they receive around 230 calls a month about treatment
abroad. No detail was available on how many of these calls are unique cases or
how many of these calls relate to planned healthcare abroad
3.1
INTRODUCTION
As described earlier in this report, patients receiving healthcare abroad will either be funded
privately (via their healthcare insurance or fee for service payment by the patient) or be
publically funded via E112 or article 56 (for planned healthcare) or via the European Health
Insurance card (EHIC) for emergency healthcare.
Section 3
14
A patient wanting to access treatment abroad, for whatever reason, may obtain prior
authorisation from their PCT, which sends the request including a clinical opinion, to the
Department of Work and Pensions (DWP) for issuing of form E112. E112 requests for
England, Scotland and Wales are sent to the Medical Benefits Team at the DWP and to the
Department of Health, Social Services and Public Safety (DHSSPS) in Northern Ireland.
Funding under article 56 is made via the PCT, reimbursing a patient that has already
received treatment for which authorisation has been given.
We obtained data on those patients that have received planned healthcare abroad by:


Collecting data from the DWP on treatment funded under E112
Collecting data from PCTs on treatment funded under article 56 (discussed in section
6)
3.2
ANALYSIS OF E112 DATA
We extracted data from the DWP records for patients who had been treated and funded
under an E112 for non-maternity care over a 12 month period. Data on these patients
included: condition, treatment, reason for treatment outside the UK, age and gender, country
of origin and country of treatment; as well as data on the authorisation of the E112, for
example, which PCT, whether the PCT used a panel or a specialised process, and the costs.
We also collected data about those patients for whom a request for an E112 authorisation
had been submitted but not granted, and the processes around the submission. Importantly
for the overall aims of the research, we also recorded who initially requested treatment
abroad for example, was it the patient themselves or was it on the advice of a clinician.
DWP provided total numbers of E112 authorisations for the same 12 month period, broken
down by country of treatment. However, we were unable to obtain a breakdown by
maternity and non-maternity. Therefore we estimated the number and country of treatment
for those who received an E112 for maternity care, by extracting the data on known nonmaternity E112s.
Data from Northern Ireland was provided separately by the DHSSPS.
3.3
3.3.1
FINDINGS FOR E112 ANALYSIS
E112s issued by the DWP
In total, there were 747 E112s issued by the DWP in the year to 13 November 2009. By
reviewing paper files, we estimate that 108 of these were non-maternity and 639 maternity.
Of all E112s issued, the top five destination countries are presented in Table 1 below.
Section 3
15
Table 3.1:
Destination country of E112 recipients for year ending 13 November
2009
Country
Poland
France
Germany
Spain
Slovakia
Others (17 countries)
Total
Number of E112s
351
106
82
57
37
114
747
Percentage of all E112s
47%
14%
11%
8%
5%
15%
100%
Whilst maternity cases account for more than 90% of all E112s issued, the non-maternity
cases were of more interest to the research. For completeness, around 100 maternity paper
cases were reviewed that indicated the reasons people wished to give birth abroad were
predominantly to be close to family. Over 50% of all maternity E112s were for maternity
care in Poland.
What is noteworthy about these requests is the requirement on pregnant women to justify
their reason for choosing to give birth abroad. Given that this is only reviewed by the DWP
and in no way influences their decision it would appear to be at best an unnecessary
requirement and at worst an intrusion on privacy.
Turning to the 108 non-maternity cases, the most significant finding is the very low numbers
actually issued. The 108 cases relate to only 64 patients, with multiple E112s being issued
for single ‘events’, in some cases to cover pre operation assessment, inpatient stays,
rehabilitation and follow up consultations.
Table 3.2 shows the distribution of these 64 patients by nationality and whether they were
treated in their home country, for the year ending 13 November 2009.
Table 3.2:
Nationality and Destination country of non-maternity E112 patients
Nationality
Belgian
British
Dutch
Finish
French
German
Polish
Slovakian
Swiss
Not known
Total
Section 3
Treatment in own
country
2
1
1
4
4
2
1
1
16
Treatment in other
country
0
47
0
0
0
0
0
0
0
47
Not known
0
0
0
0
0
0
0
0
0
1
1
16
As can be seen from Table 3.2, the majority (73%) of all non-maternity E112s were issued to
British nationals. Of the 16 non-British recipients where the nationality was known, all were
treated in their own country. It is of note that the E112s issued to non-British nationals are
almost in their entirety issued as maternity requests. Those that are non-maternity were
almost entirely issued to patients who wanted to be close to family to receive treatment –
usually as they had cancer. There is no evidence that E112s are being used by foreign
nationals as a route to access funding for healthcare elsewhere in the EU.
Of the 47 British nationals with an E112, Table 3.3 shows that treatment was provided in
eleven other EU countries.
Table 3.3:
Treating country for British nationals with a non-maternity E112
Treating Country
Austria
Belgium
Finland
France
Germany
Holland
Italy
Norway
Spain
Sweden
Switzerland
Grand Total
Number
3
12
1
13
2
2
1
2
1
3
7
47
Percentage
6%
26%
2%
28%
4%
4%
2%
4%
2%
6%
15%
100%
Only seven of the 47 (15%) of the E112s for British nationals were issued because the
patient had requested treatment abroad. Of these three appeared to live abroad or planned
to live abroad, two wanted follow up treatment in the clinic where they had received earlier
treatment, and two because they felt the quality of treatment would be better overseas. The
remaining 40 patients were referred abroad by their consultant or their PCT (potentially on a
consultant’s advice) with 36 (90%) of these referrals because treatment was unavailable in
the UK.
There was no particular pattern or cluster of conditions for E112s issued to British nationals,
although conditions could all be described as significant including cancer, gender
dysmorphia and severe epilepsy.
The records indicated that around 45 PCTs or commissioning bodies agreed to fund a nonmaternity E112 with around 25 only issuing them to one patient. One PCT agreed to fund
overseas treatment through an E112 to nine patients. This was more than any other PCT.
3.3.2
E112s requested from the DWP but not issued
In addition to the 64 patients being issued with an E112, a further 104 people requested
non-maternity E112s that had not at the time of the research been issued. In most of these
cases it would seem unlikely that an E112 would be issued. Thirty two (31%) were
Section 3
17
individuals writing to the DWP for funding for treatment they had already received. However,
E112s appear not to be normally issued retrospectively (although a few exceptions to this
rule were found). Of the remaining patients the majority were writing to the DWP to request
treatment abroad with the DWP informing them they had to contact their GP and local
healthcare commissioner to see if they would fund treatment abroad.
The nationalities of patients requesting an E112 but not having one issued indicates that
41% of the small number of total requests is from Polish nationals and 19% from British.
With such a small sample care must be taken to read too much into the reasons for requests
for the E112s that were not issued. The reasons for non-issuance from the DWP
perspective were due to failure to comply with the process rather than clinical need. The
majority of these requests were because of familiarity with clinicians overseas, the absence
of a language barrier or the desire to be close to family.
Of the 20 requests relating to British nationals, only nine were requests from the patients
themselves with the remainder requests from treating hospitals overseas looking for
reimbursement sometimes through an E107. The E107 is a form used to request proof of
entitlement to benefits by a treating healthcare system to the 'home' country and would
ordinarily relate to emergency treatment where an EHIC was not presented by the
patient. The numbers of E112 requests via E107 are very small however and, whilst
illustrating some confusion in the system that is European wide, are not worth further
comment. Of the patients requesting an E112, where a reason was recorded it was either
because they lived abroad for part of the year or they had had emergency treatment under
EHIC and the hospital has asked the patient for an E112 to cover necessary planned follow
up treatment.
3.3.3
Enquiries about E112
The DWP keep a log on the number of enquiries made via telephone about the E112. Over
the past ten months this has averaged around 230 calls per month or around 3,000 calls a
year. Given that only about 850 people requested via writing or were issued an E112 over
the preceding twelve months, it is not clear what these calls relate to, although there can be
multiple calls about the same case.
3.3.4
E112s issued in Northern Ireland
Data was provided by the DHSSPS on E112s issued between April 2008 and September
2009. In total, there were 24 E112s issued, 13 of which were maternity. Of the nonmaternity E112s, seven were for treatment in the Republic of Ireland and two each in
Germany and Belgium. The patients going to the Republic of Ireland did so because
treatment was not available in the North or the waiting time was too long. Patients went to
Germany and Belgium for operations that followed a separate pathway to that in the UK.
3.3.6
Estimated costs of non-maternity E112s
Section 3
18
The objective was to generate an upper bound to the total cost. We took the conditions and
treatments for each of patients about whom we had collected data. As far as possible, we
took costs from Reference Costs if the costs were not provided in the patient record at DWP.
However, we had to make assumptions in the calculation of the costs, as many of the
treatments neither had costs in the patient records, nor were there published reference costs
as the treatment was not always available in the UK.
Therefore our methodology was to:
 Use the costs given where provided, and copy these to the same treatments where
no estimate was given (for example, in costing Proton Therapy, six patients had
received it, but only one estimate of costs were given so this same cost was applied
to the remaining five)
 Find the most expensive ‘close’’ treatment for those treatment where a good proxy
can be found (for example, to cost “ankle surgery – retinaculum”, we used “major foot
procedures for non-trauma” with an inpatient stay. We then added 10%, and rounded
it to the nearest £1,000)
 Where no good proxy could be found, we used a similar treatment from the E112
costs
 Euros were converted into pounds at a 1:1 exchange rate
 Where a range of costs was given in an E112, the upper estimate was used.
Thus, all our estimates generate the most expensive plausible cost. Our estimate comes to
£1.1million, or around £17,000 per patient. These costs exclude all travel and
accommodation. Appendix A provides the detailed calculations.
3.4
ANALYSIS OF EHIC CLAIMS
It is estimated by the DWP that around 40,000 EHIC claims will be made this year. The
purpose of the visit to the DWP was not to explore EHIC claims, but in conversation with
people in the Medical Claims department there was a suspicion that many EHIC claims were
dental or orthopaedic related and may actually be health tourism and not genuine
emergencies. Unfortunately, little data is captured on EHIC claims. They are processed and
paid in batches of several thousand. The claims themselves are often in a foreign language
with little supporting information behind the claim therefore we could not evidence the belief
that large numbers of EHIC claims for dental or orthopaedic were inappropriate.
3.5
ANALYSIS OF ARTICLE 56 DATA
Data on patients treated via article 56 route can only be obtained from health care
commissioners, as they authorise and pay for healthcare under this route. There is no
central data collection. A survey was sent to commissioners requesting information about
the processes adopted to review and authorise requests to receive healthcare overseas
(discussed in more detail in section 6). This survey also requested information about
authorisations under E112 (to cross check with data collected from DWP) and under article
56. Analysis of article 56 data is given in section 6.
Section 3
19
Section 4:
Analysis of the Public Survey
Key findings
 Of a 1004 member sample, stratified in line with characteristics of members of the
Treatment Abroad study and recipients of E112s, a small proportion had previously
considered travelling abroad for treatment;
 An even smaller number had previously travelled abroad for planned healthcare, and
only 3 individuals used the NHS as a primary source of funding;
 Although participants indicated a degree of interest towards receiving healthcare abroad
funded by the NHS, processes for accessing further information were not found to be
wholly clear;
 Clearer and easier access may increase the numbers of those using healthcare abroad
service, but following analysis of current numbers and the extent of disadvantages
reported, it would be unlikely for a large increase in numbers;
 Results indicate that middle-aged people are more aware of the service, but younger
people have greater access to information and are more willing to travel;
 As this age group is less likely to require extensive treatment, this further supports the
notion that numbers requesting healthcare abroad will not dramatically increase;
 The findings of our survey are in line with those from the EU Flashbarometer survey;
 Consistent messages from across all EU counties are that whilst many might consider
travelling outside their country to receive healthcare, neither our survey, nor the EU
survey suggest that this consideration will be translated into demand and that the
numbers are likely to increase under current supply of healthcare, such as the
management of waiting lists.
4.1
METHODOLOGY
4.1.1
Introduction
A telephone survey was conducted on a sample of the general public in order to assess
knowledge, attitudes and preferences about travelling abroad for healthcare. The survey was
undertaken by QA Research23, a social and health care market research company
commissioned by YHEC to carry out the interviews. This section summarises the findings.
More detail on the methodology and the findings including tabular analysis is given in the
technical appendix to this report.
4.1.2
Sample
In total, the sample comprised 1004 members of the general public. A sampling strategy
was devised which reflected the age and gender structure of the Treatment Abroad
23
http://www.qaresearch.co.uk/
Section 4
20
respondents24 and those in receipt of E112s. As a result of this stratification, the sample was
younger than the general population that uses health care inside the UK.
4.1.3
Questioning route
The development of the questioning route used in the telephone survey (see Technical
Report, Appendix A) was informed by findings from the literature review (see section 2) and
the analysis of collected data from the Department of Work and Pensions (see section 3).
Further to this, comments were received from the DH team and QA Research. The following
areas were examined in the telephone survey interview guide:


Whether respondents had received treatment abroad;
If they had, what processes were adopted (how information was obtained, how
choices were made);
If they had, what were their reasons for seeking treatment abroad;
If they had not, for what conditions would they travel and why;
If they had not, what paths would they take to obtain information;
Interviewees’ knowledge of NHS funded routes;
Whether NHS funded routes would be used or why they would not be used.





4.1.4
The Telephone survey
Researchers from QA Research carried out the survey using a computer-assisted telephone
interviewing (CATI) system. The survey was carried out in three phases (see figure 4.1)
Figure 4.1
Three phases of the survey
The pilot phase
(50 respondents)
The main phase
(750 respondents)
The final phase
(204 respondents)
24
Treatment Abroad. Medical Tourist Survey 2008: The motivations and experiences of 648 medical tourists.
Intuition Communications. Accessible at: www.treatmentabroad.com. NB: Individuals receiving cosmetic
surgery abroad were exempt from analysis as this treatment would not be funded by the NHS
Section 4
21
The survey was initially piloted on 50 respondents. Once the pilot had been completed, the
main phase was undertaken where 750 respondents were surveyed. However, the
proportion of respondents from ethnic backgrounds was too low, so a final phase was
undertaken with 204 respondents, sampled so as to increase the proportion of individuals
from ethnic backgrounds in the total sample.
4.1.5
Demographics of participants
As the sampling strategy used was aimed at reflecting the age and gender structure of the
Treatment Abroad respondents and those in receipt of E112s that the sample was overall
younger than that of the general population that uses health care inside the UK, with the
highest percentage of individuals falling into the age bands of 45-64. However there was
fairly even coverage of both genders (42% males, 58% females) in the sample. A more
detailed analysis of the demographic make-up of respondents is given in the technical
appendix.
Table 4.1
Age of participants (Base 1004)
Age
n
18-24
25-34
35-44
45-54
55-64
65-74
75-84
85+
22
73
190
270
270
136
40
3
Percentage of
respondents (%)
2
7
19
27
27
14
4
0
General Population (%)*
8**
19
20
17
15
11
7
3
*Taken from 2001 census. Split of population aged 20 and over
**Aged 20-24
Following the final sample, individuals from White British backgrounds comprised 94%
(n=906) and 6% (n=56) were individuals from BME backgrounds However, since the
ethnicities of individuals who seek healthcare abroad is unknown we do not know whether
the ethnicity of the sample was an accurate reflection of individuals who travel abroad for
planned healthcare. Yet a comparison of the percentage of individuals from ethnic
backgrounds in the sample (5.7%) to the general population (7.9%25) illustrated that the
sample was a fairly accurate representation of the general population.
Participants were classified into social grades based upon their socioeconomic status. The
proposed classifications, as presented in table 4.2, indicate the sample contained a high
proportion of individuals from middle to lower middle class backgrounds. However, the
socioeconomic class of individuals who have sought planned health care abroad is
unknown, making it unfeasible to make appropriate judgments of accuracy in reflecting the
population most likely to travel abroad for health care.
25
Source: The UK Population by ethnic group, April 2001. Office for National Statistics [Online]. Available at:
http://www.statistics.gov.uk/cci/nugget.asp?id=273
Section 4
22
Table 4.2
Social Grade of participants
Social Grade
Description
Number of respondents
A
Upper middle class
33
B
Middle class
293
C1
Lower middle class
267
C2
Skilled working class
196
D
Working class
169
E
Subsistence
46
Total
1004
Note: Social classification is based upon the National Readership Survey (JICNAR)
4.2
4.2.1
FINDINGS
Participants reported to have lived abroad
The first set of questions was designed to define and delineate members of the sample who
had received healthcare abroad as a result of residing outside of the UK. Of our sample of
1004, 11% (n=114) lived abroad. Of the 114, 85% (n=97) lived in the EU. Only 15% (n=17)
of the 114 individuals who lived abroad received planned healthcare. Out of the 17
individuals who received planned healthcare abroad, whilst living abroad, 5 respondents did
not specify the type of healthcare received. The most frequently reported types of
healthcare received were for fractures (n=2) and giving birth (n=2). Other types of
healthcare were individually reported and ranged from minor surgery to vaccinations.
4.2.2
Participants reported to have travelled abroad and received unplanned or
emergency healthcare
The line of questioning in the survey then moved towards individuals who had travelled
abroad and received unplanned or emergency healthcare, in order to separate that group
and make the distinction. Of the entire sample, 461 (46%) individuals had previously
travelled abroad in the EU. Only 9 of the 461 individuals who travelled abroad in the EU
received unplanned or emergency healthcare.
Of these 9 individuals who had received unplanned or emergency healthcare in the EU, 3
individuals used private healthcare cover and 8 individuals used an EHIC card (2 individuals
usd both methods). None of the 8 individuals who used their EHIC cards reported any
problems in doing so.
The emergency or unplanned healthcare was received in 4 countries with Spain being the
most frequent location (n=5), followed by France (n=2), and Greece and Tenerife (1 in each)
4.2.3
Awareness of accessing planned healthcare abroad
The entire sample was asked about their level of awareness regarding planned healthcare
abroad funded by the NHS and the available methods of accessing this service. 62%
(n=624) were aware of being able to receive planned healthcare abroad funded by the NHS.
Section 4
23
However, of these 624 individuals who were aware of this service, less than half (n=257)
were aware of where to go for advice on this service.
When analysing the demographic make-up of the group, we found that awareness of
planned healthcare abroad is more prevalent within middle aged and elderly people as
opposed to younger individuals, which reflects age characteristics of travel abroad
respondents and those in receipt of E112s. However knowledge of the methods and
systems in place in order to obtain information regarding receiving healthcare abroad
appears to be limited. We also found relatively low levels of knowledge in minority groups.
36% of Black individuals and 42% of Asian individuals in the sample reported awareness in
comparison to 63% of white individuals. When considering the higher proportion of white
individuals in the sample compared to BME, the level of reported knowledge is relatively low
in ethnic groups.
The entire sample, but excluding those whom had stated they were aware of where to go for
advice, were then asked about the mediums of advice they would use if considering planned
healthcare abroad (n=637). Table 4.7 presents the 7 most frequent responses. Whilst 111
(18%) individuals stated they did not know where to go to seek advice, the most frequent
response was to consult a Dr or GP (n=268). The second most frequent response was to
look on the internet (n=112). 37 individuals stated they would approach the hospital for
advice, whilst 36 would approach the NHS in general. The Post Office (n=11) and Insurance
Companies (n=11) were other suggested mediums. The range of mediums of advice
reported in these results indicates a lack of clear and obvious sources of advice for those
seeking information on planned healthcare abroad.
Table 4.7
Most frequent mediums of advice participants would use (Base 637)
Medium of Advice
Doctor
Internet
Don’t know
Hospital
NHS
Post Office
Insurance Company
n
268
112
111
37
36
11
11
%
42
18
17
6
6
2
2
A breakdown of the mediums sought by age revealed that percentages of individuals in each
band were fairly consistent across each of the reported mediums. An exception was the
higher percentage of individuals aged 18-24 (23%) and 25-34 (19%) who would use the
internet to seek advice, in comparison to lower percentages in older age bands. This
naturally reflects the younger generation’s higher level of familiarity with technology.
4.2.4
Perceptions of planned healthcare abroad
The entire sample was asked about whether they had considered going abroad for planned
healthcare.
Section 4
24
Of the entire sample (n=1004), only 45 individuals stated they had previously considered
planned healthcare abroad. Over half of the 45 participants (n=26) would consider planned
healthcare abroad in EU countries. 11 individuals would consider countries outside of the
EU, whilst 6 participants did not consider any country in particular and 2 did not disclose.
A cross tabulation by age and gender in participants who had previously considered going
abroad indicated very little difference by gender. In terms of age, a higher percentage of 1824 year olds (9%), 35-44 year olds (7%) and 45-54 year olds (4%) were. This outcome is not
entirely typical of Treatment Abroad respondents and those in receipt of E112s. It appears
that older age groups are more aware of planned healthcare abroad funded by the NHS, but
younger people are more willing to consider it as a viable option.
A further cross tabulation was conducted on the ethnicity and gender of participants who told
us they had considered receiving planned healthcare abroad. The results were not typical of
the stratified sample, with higher percentages in Black (18%), Asian (11%) and other
minorities (15%) being more likely to consider going abroad for planned healthcare
compared to White respondents (4%). Therefore consideration of planned healthcare
abroad was much higher in participants from non-white backgrounds.
The 45 participants whom had considered healthcare abroad were asked to provide reasons
as to why they had considered planned healthcare abroad. The most frequently reported
reasons are presented in table 4.8 with comparisons to outcomes in the Treatment Abroad
Study where results are fairly similar.
Table 4.8
Most frequent reasons for participants considering healthcare abroad
(Base: 45)
Reason
n
%
Could not afford private healthcare in
UK
To avoid long waiting times
Perceived higher quality of facilities
abroad
Cheaper
Dissatisfaction with existing
healthcare provider
17
38
Participants in
Treatment Abroad
Study (%)
64
13
8
29
18
47
38
6
6
13
13
64
-
We asked the whole sample what they perceived to be the advantages and disadvantages
of travelling abroad for treatment funded by the NHS. The results are shown in table 4.9. The
most frequent reason was an inability to afford private healthcare in the UK. The second
most frequently reported reason was the avoidance of long waiting times in the UK (n=13).
8 participants claimed the perception of higher quality healthcare facilities abroad was a
reason for their consideration, whilst cheaper healthcare costs was a primary consideration
for 6 individuals.
Section 4
25
When asked to expand on their dissatisfaction with existing healthcare providers, individuals
claimed dissatisfaction with NHS staff (n=3), cleanliness in NHS hospitals (n=1), lack of
speed (n=1) and ‘everything’ (n=1).
With only 45 individuals reporting to have considered healthcare abroad in the past, there is
not a great deal of concern to be drawn. The reasons provided are based upon costs
(inability to afford private care and seeking cheaper care abroad) or dissatisfaction with
current services (waiting times, perception of higher quality facilities abroad).
Table 4.9
Perceived advantages and disadvantages of travelling abroad for
treatment with the NHS (Base 1004)
Advantage
To avoid long waiting times
No advantages
Perceived higher quality of
facilities abroad
Perceived higher quality of
staff abroad
Private Healthcare not as
expensive abroad
Access to treatments not
available in the UK
Combine with holiday
Concerns about cleanliness in
UK hospitals
Can receive health at own
convenience
It would be cheaper
Concerns about contracting an
infection
Able to access treatments not
available on NHS
Don’t know
Dissatisfaction with current
healthcare provider
For the weather
Would only go for cosmetic
surgery
There is more choice
It would depend
If family live there
A more personal service
Already covered for it
Food is much better
Good for recovery
It would be guaranteed
Understanding those treating
Section 4
n
%
503
50
296
29
105
10
60
6
45
4
42
4
25
2
22
2
14
1
14
1
13
1
13
1
13
1
6
1
6
1
3
0
3
2
2
2
0
1
0
1
1
1
1
0
0
0
0
0
0
Disadvantage
I want to have care close to my
family and where I live
Concern about not speaking
the same language
Travelling
Too complicated to organise
Happy with my NHS care
Cost
No disadvantages
Don’t know
General discomfort going
abroad
Care might not be up to NHS
standards
I am healthy and do not need
healthcare
NHS should not be funding
healthcare abroad
Getting time off work would be
awkward
May be difficult if disabled
It depends on the
country/circumstances
Don’t think I’ll be able to get
insurance
Don’t have a passport
No need
Food would be an issue
Unable to watch TV
Waiting times abroad may not
be better
The work is done too quickly
n
%
285
28
223
21
211
21
86
9
70
7
65
6
64
6
31
3
30
3
13
1
9
1
7
1
6
1
5
0
5
0
3
0
3
3
1
1
0
0
0
1
0
1
0
26
you more
Spending time abroad anyway
1
0
You wouldn’t have to pay in
1
0
cash
100
TOTAL
1196* 100
TOTAL
1123
*Please note, categories are not exclusive and responses do overlap. Respondents could give more
than one response.
Although 29% of the sample did not perceive any particular advantages towards planned
healthcare abroad, the most frequently reported advantage was the avoidance of long
waiting times in the NHS, and was shared by 50% of the sample (n=503). The perception of
higher quality healthcare facilities abroad was the second highest advantage report (n=105),
whilst cheaper costs (n=45) and access to treatment that are not available in the UK (n=42)
were also reported.
The most frequent disadvantage, reported by 28% of the sample, was the inability to have
family close by when undergoing treatment (n=285). The second most frequently reported
issues were concern over not speaking the same language as healthcare providers abroad
(n=215) and issues with regards to travelling before and after treatment (n=211). Elements
regarding a lack of awareness towards healthcare abroad service funded by the NHS were
expressed through perceived disadvantages of complicated logistics in organising the
healthcare (n=86) and cost (n=65). However, a positive view was presented in that 70
individuals reported they were happy with current NHS care and saw no reason to consider
travelling abroad.
We examined the demographic make-up of those individuals who stated avoidance of long
waiting lists to be an advantage of receiving planned healthcare abroad funded by the NHS.
The highest frequencies of this perception were reported in the middle-aged bands; 52% of
individuals aged 35-44, 50% of individuals aged 45-54 and 54% of individuals aged 55-64
shared this perception which is typical of the Treatment Abroad respondents and recipients
of E112s. Very little difference was found across genders in this cross tabulation.
A cross tabulation of ethnicity and age in response to the same query indicated this
perception was predominantly shared by white individuals, with low percentages of response
from black respondents (27%), Asian respondents (37%) and individuals from other
backgrounds (35%).
The second most frequent advantage reported was the perception of higher quality services
abroad. A cross tabulation by age and gender revealed that a higher percentage of females
(29%) and males (38%) aged 18-24 shared this view, whilst the most frequently populated
age bands (45-54 and 55-64) had substantially lower percentages in comparison. A cross
tabulation of ethnicity and gender for this query indicated this perception was held fairly
equally across ethnicities, although Black (17%) and Asian (25%) females had higher levels
of response than males.
Only 37% of respondents did not know that they could go abroad for planned healthcare
funded by the NHS prior to the survey. Of this group of respondents, only 59% stated they
Section 4
27
would now considering going abroad. Of the entire sample (n=1004), only 22% who were
previously unaware of the healthcare abroad option reported they would consider it an option
now they are aware. Considering demographic make-up, the highest percentages of
individuals who would consider healthcare abroad, having previously being unaware prior to
the survey, were found in the younger age bands of 18-24 (79% of women and 63% of men)
and 25-34 (70% of women and 76% of men). Therefore, the numbers of individuals who
would consider healthcare abroad are fairly low.
4.2.5
Participants who travelled abroad to receive planned healthcare
The entire sample was asked if they had travelled abroad with the primary reason to receive
healthcare treatment. Only 7 (less than 1%) individuals out of the entire sample had
previously travelled abroad with the primary reason to receive planned healthcare funded by
the NHS.
Of those 7 individuals, 4 were treated in EU countries, whilst 3 were treated in non EU
countries. All of the 7 individuals were female, 4 of whom fall into the age bands of 35-44
and 45-54. 4 of the individuals were White British (58%), 1 being White European, 1 being
White Other and 1 Asian other. We requested information of how their healthcare abroad
was funded and found that 5 used private payments, 1 used personal health insurance and
only 1 used the NHS as a funding source. This further indicates the very low demand on the
NHS for funding services abroad. The individual who received healthcare abroad funded by
the NHS was a White European female aged 35-44, and stated she sought healthcare
abroad as she wanted to feel more at home in her own county. She sought funding before
travelling and did not recall whom they directly approached when initially trying to obtain
funding.
The 7 individuals were asked about their reasons and motivations for seeking planned
healthcare abroad. Table 4.10 presents the all of the responses which are not exclusive and
overlap. Perceptions of healthcare services abroad being of a higher quality was a
motivation for 2 individuals, and the cheaper cost of healthcare abroad was also a motivation
for 2 individuals who paid privately. Other reasons provided included the inability to receive
treatment in the UK and concern about the cleanliness of UK hospitals. When comparing
these reasons to those of individuals considering going abroad for planned healthcare (table
4.8), there are many similarities. Cost motivations such as cheaper services abroad and an
inability to afford private healthcare are present in both types of responses. Dissatisfaction
with current healthcare provider and perception of better medical facilities abroad were also
common in both types of responses. The individual whom sought healthcare abroad
because they could not receive treatment in the UK was a White British female aged 65-74.
These results confirm the apparent key motivations for going abroad for planned healthcare,
being cost and perceptions of higher quality of and quicker care abroad.
Section 4
28
Table 4.10
Reasons for going abroad for healthcare (Base 7)
Reason
Perceived higher quality of services abroad
Was cheaper to go abroad
Could not receive treatment in UK
Concerns about cleanliness in UK hospitals
Fell ill on holiday
Felt more comfortable in own country
n
2
2
1
1
1
1
%
29
29
14
14
14
14
The individuals were asked about their methods of selecting healthcare providers abroad.
Table 4.11 presents the results of this inquiry, indicating the internet and recommendations
from friends or families to be the two most frequent methods of selecting healthcare
providers. One individual who used the internet recalled it to be a people logistics website.
Other individual reasons were provided such as already being acquainted with the
consultant/facility or already receiving treatment at that facility.
Table 4.11
Methods of selecting healthcare providers (Base 7)
Method of selection
Internet/website
Recommendation from friend/family
Intermediary healthcare broker (insurance for holiday)
Already acquainted with consultant/facility
Already receiving treatment from consultant/facility
n
2
2
1
1
1
%
29
29
14
14
14
Out of the 7 individuals who travelled abroad for planned healthcare, 6 travelled only once
whilst 1 individual travelled twice for services on the same condition. When asked if they
consulted their UK GP after their treatment abroad, 1 person did whilst 6 did not. Similarly,
when asked if they were happy with the treatment they received abroad and whether they
would consider doing it again, 6 individuals stated they were satisfied and would consider it
again, whilst 1 individual was very dissatisfied and would not consider it again. No reason
was provided for this dissatisfaction. This clearly appears to be an individual with a negative
experience, yet in all other cases there appeared to be no problems or causes for complaint.
With only 7 individuals out of a 1004 member sample (stratified in line with characteristics of
Treatment Abroad respondents and recipients of E112s) having previously travelled abroad
for planned healthcare, there appears to be a very low volume of individuals using this
service.
4.2.6
Children of participants who had travelled abroad to receive planned
healthcare
The entire sample of participants was asked whether their children had travelled abroad for
planned healthcare, out of which only 4 children had travelled abroad for planned
healthcare. Of those 4 children, 3 were treated in the EU (2 in Spain, and 1 in Hungary) and
1 treated in a non-EU country. Treatment for 2 children was by private payments; the
parents did not attempt to use an EHIC card or seek funding from the NHS. The other 2
Section 4
29
children were covered by the NHS and funding was sought before travelling. The reasons or
motivations provided as to why the children travelled abroad for healthcare were individual
and contextualised to each individuals personal circumstances, as shown in table 4.12.
Again, as with reasons provided by participants who had travelled abroad, the inability to
receive treatment in the UK was a reason provided as to why the child sought healthcare
abroad. In this particular case, a 3D scan was required which is not currently available on
the NHS. The reason of combining the treatment with a holiday is also consistent with the
advantages reported for receiving healthcare abroad.
Table 4.12
Reasons for taking child abroad for healthcare
Reason
Christmas holiday
Treatment did not work in UK
Could not receive treatment in UK (3D prenatal scan)
In the army
Total
n
1
1
1
1
4
%
25
25
25
25
100
The methods of selecting healthcare providers for children arose out of individual
circumstances (table 4.13). There are similarities between the methods presented here and
those provided by adults who received planned healthcare abroad, such as already being
acquainted with the physician or facility.
Table 4.13
Methods of selecting healthcare providers for children (Base 4)
Method of selection
Already acquainted with consultant/facility
Other UK healthcare provider- BUPA
Army
Original Dr in Spain
Total
n
1
1
1
1
4
%
25
25
25
25
100
However, the number of times the participant’s children travelled abroad for healthcare
differs from those provided by participants. Two children travelled abroad only once for
healthcare, whilst one child travelled twice and another travelled 5 times or more, both for
the same condition. 2 participants stated they were ‘very satisfied’ with the services they
received and the other 2 participants stated they were ‘satisfied’ and all would allow their
children to travel abroad again for treatment.
4.3
4.3.1
SUMMARY AND DISCUSSION
Awareness of NHS funding for unplanned and planned healthcare
The results of the survey indicate there is a high level of awareness of the EHIC card and its
use when receiving unplanned healthcare abroad. Of the 9 individuals who received
unplanned healthcare in the EU, 8 used an EHIC card, implying effective strategies of
advertising and implementation of the system. Although awareness of NHS funding for
Section 4
30
planned healthcare abroad was reported by more than half of the sample (n=624), more
than half of the entire sample were unaware of where to seek information on this service
(n=637). The extent and range of mediums suggested by participants as to where they
would seek advice for planned healthcare abroad implies a lack of a clear advertised
pathway for this service. The most frequent response was to consult general practitioners
who are not formally a part of this programme nor is it guaranteed they possess the correct
information to supply to interested patients.
4.3.2
Perceptions of planned healthcare abroad funded by the NHS
The number of individuals whom had previously considered planned healthcare abroad
comprised a very small proportion of the stratified sample (n=45), indicating either little
interest, lack of awareness, or lack of knowledge as to how to arrange the service. Reasons
for considering healthcare abroad were centred on primary themes: cost (inability to afford
private healthcare and cheaper services abroad) and dissatisfaction with NHS services
(perception of higher quality of services and facilities abroad and problems and waiting
times). The two reasons are interrelated; the inability to afford private healthcare as a
motivation stems from a desire to seek healthcare outside of the NHS, implying a
dissatisfaction services currently provided by the NHS. Yet the number of individuals whom
had previously considered healthcare abroad as an option is small, indicating little effect on
the NHS.
More than half of the sample stated they would consider planned healthcare abroad in the
future (n=622) indicating a reasonable level of interest in the service. Further to this, more
advantages of receiving healthcare abroad (n=1196) were reported than disadvantages
(n=1123). The most frequent advantages reported relate to the motivational factors of
participants previously considering planned healthcare abroad, that of dissatisfaction of NHS
services and the associated cost of seeking private healthcare. Dissatisfaction was of
greater importance within the reported advantages with 50% of the sample reporting
avoidance of waiting times to be a primary advantage. However, a substantial number of
disadvantages were also reported including the inability to have family close by (28%),
language barriers (21%) and the need to travel (21%). Therefore although a reasonable
level of interest was reported towards planned healthcare abroad in the future primarily
motivated by dissatisfaction with NHS services, a sizeable proportion of disadvantages were
also reported. 70 individuals also stated they were happy with the services they currently
receive on the NHS.
Only 37% of the sample was unaware of the services offered by the NHS for healthcare
abroad prior to the survey. Of this 37%, only 59% stated they would consider using the
service in the future. Therefore, of the entire sample (n=1004), only 22% of individuals who
were previously unaware of the healthcare abroad option reported they would now consider
it to be an option, so very little conversion of interest took place. With such small individuals
registering their interest, and with such a large amount of reported disadvantages in relation
advantages, there is little concern to be drawn.
Section 4
31
4.3.3
Participants whom had previously received planned healthcare abroad
Of the entire sample, only 7 participants and 4 children of participants reported they had
previously received planned healthcare abroad. Further to this, only 1 participant and 2 of
the 4 children used NHS as a primary source of funding for the healthcare they received
abroad. Again, this implies minimal burden to the NHS, with such small numbers being
reported to use this service out of our1004 member stratified sample
The reasons for this small number of individuals seeking planned healthcare abroad echo
those reported as motivational factors for considering healthcare aboard and the reported
advantages of this service. Dissatisfaction with NHS services and costs were equally
reported as reasons for seeking healthcare abroad. For the participants’ children, a greater
emphasis was placed on the inability to receive the necessary treatment within the NHS and
other personal circumstances. The small numbers being reported of individuals travelling
abroad gives little cause for concern.
4.3.4
Characteristics of sample- who travels abroad for planned healthcare?
As previously stated, the sample used in this study was selected on the basis of
characteristics similar to individuals in the Treatment Abroad study and recipients of E112s.
However, the ethnicity of individuals who have travelled abroad for planned healthcare is
unknown, as no formal recording has been made. Although responses from either gender
were found to be fairly equally consistent throughout the survey, the frequency of some
factors were greatly influenced by age and gender.
Age
Findings indicate awareness of planned healthcare increases with age, as 73% of 270
individuals aged 55-64 and 61% of 270 individuals aged 45-54 were aware of planned
healthcare abroad in comparison to 27% of 22 individuals aged 18-24 in the sample. .
However, in terms of accessing information regarding healthcare abroad, a high proportion
younger individuals (in 18-24 and 25-34 age bands) reported the internet to be their first port
of call. Although this is reflective of the younger generations inauguration and familiarity the
technology and the digital age, there is a lot of comprehensive information regarding NHS
funded healthcare abroad, therefore the younger individuals report a more fruitful method of
accessing information, as opposed to the middle aged groups who reported a doctor to the
first port of call.
Therefore it is indicated that middle aged white groups are more aware of NHS funded
healthcare abroad, yet younger individuals have a greater grasp of accessing
comprehensive information on the service. In terms of perceived advantages of receiving
healthcare abroad, the avoidance of long waiting lists was a view held primarily by middle
aged individuals falling into age bands 35-44 and 55-64, which is typical of the Treatment
Abroad sample. Whilst the perception of better quality facilities and care abroad was more
frequently held by younger age groups, which may indicate younger individuals perceive the
NHS as providing a lower quality service, whilst the main concern. Further to this, higher
Section 4
32
percentages of previous consideration towards healthcare abroad were found in the younger
age bands of 18-24 (9%) and 35-44 (7%) compared to individuals aged 55-64 (3%). This
implies that individuals who fall into middle to elderly age bands are more aware of the
service, but younger individuals have greater access to knowledge and overall are more
willing to consider travelling abroad for healthcare.
Ethnicity
It was also found that knowledge of healthcare abroad appeared to be limited among people
from different ethnic backgrounds. However high frequencies were reported of individuals
from ethnic backgrounds whom had previously considered healthcare. Therefore, although
awareness is recorded to be low among individuals from ethnic backgrounds, willingness to
travel abroad and receive planned healthcare is high.
4.4
COMPARISON OF SURVEY FINDINGS WITH FLASHBAROMETER FINDINGS
The survey, conducted in May 2007, was carried out with citizens in all 27 member states.
1,007 interviews were undertaken with UK citizens. In the EU survey, on average 4% of
citizens received medical treatment outside their national borders in the previous 12 months
(with a range of 2%-8%, and Luxembourg as an outlier at 20%). According to the EU survey
3% of UK respondents had travelled abroad. The EU survey did not differentiate the
mechanisms for receiving treatment abroad. Our survey found that 17 individuals received
healthcare abroad whilst living and working abroad, 9 received unplanned healthcare whilst
travelling abroad, and 7 travelled abroad for planned healthcare. In total, therefore 32 of our
respondents had received healthcare abroad, equating to 3%, and thus matching the EU
survey results.
The EU survey investigated whether citizens would be willing to travel to another EU country
to receive medical treatment. The responses ranged from 88% of Cypriots down to 26% of
those from Finland. 54% of those from the UK indicated that they would be willing to travel.
According to our survey, 62% were aware that they could travel abroad to receive planned
healthcare funded by the NHS, but only 4% had considered going abroad for planned
healthcare. This group appeared to be a younger age-group, which accords with the EU
findings that willingness to travel for healthcare decreases with age, and increases with
educational attainment. The EU survey looked at correlations between a series of questions
(assumptions that such treatments are covered by regular health insurance, previous
experience of treatment elsewhere in the EU, and preparedness to travel abroad for
treatment), and found that there is no relation between any two of the three factors,
suggesting that the answers do not reflect well established attitudes.
The EU survey asked respondents about factors that might motivate them to obtain health
services outside their country. They found that the major reason was the inability to receive
treatment in their home country (95% from UK; 91% EU average), followed by an expected
better quality of treatment (81% from UK; 78% EU average), to see a renowned specialist
Section 4
33
(88% from UK ; 69% EU average), to receive treatment more quickly than at home (86%
from UK; 64% EU average) and to receive cheaper treatment than at home (66% from UK;
48% EU average). Higher percentages of UK citizens identified these factors across all
factors (including the comment on cheaper treatment, which is a little surprising given that
NHS care is mostly free; respondents were possibly commenting on private healthcare).
These factors are those that were identified by respondents in our survey. However, whilst
the EU survey prompted with factors, our survey did not.
The EU survey also asked about factors that discouraged citizens from obtaining treatment
elsewhere in the EU. 86% of EU respondents said it was more convenient to be treated near
home( 98% of UK respondents), 83% said they were satisfied with the healthcare they could
receive at home (86% of UK respondents), 61% said they did not have enough information
about the availability and quality of medical treatment abroad (70% of UK respondents), 49%
gave language reasons (64% of UK respondents), and 47% said they could not afford to
receive medical treatment abroad (59% of UK respondents). Again, higher percentages of
UK respondents identified these factors especially that of convenience, and again these
factors were identified by respondents in our survey.
Therefore overall, the findings from our survey accord broadly with those from the EU
survey. Consistent messages from across all EU countries are that whilst many might
consider travelling outside their country to receive healthcare, small numbers do, and neither
our survey, nor the EU survey, suggests that the numbers are likely to increase. Motivating
factors and barriers were also similar across the surveys, with UK respondents to the EU
survey identifying convenience and the desire to be treated closer to home as the main
barrier for not travelling abroad.
Section 4
34
Section 5:
Focus Groups with members of
the general public
Key findings
 Experiences of healthcare abroad and in private facilities in the UK, were excellent;
those who had used these facilities praised them highly, including the quality of the staff
and clinical outcomes. None had aftercare problems, nor made complaints;
 Experiences of NHS healthcare ranged from excellent to very poor. Excellent care
seemed to be of the specialist nature, although many participants said they had received
good quality NHS care. Participants had made complaints or had serious reservations
about the quality of some care received;
 Expressed concerns about the NHS were three-fold: quality of staffing, particularly
nursing, where staff appear to be rushed and unable to give more personal attention to
patients and basic needs; levels of cleanliness and the risk of hospital acquired
infections; and the length of waiting times, where waits of 6 – 18 weeks (within DH
guidelines) were seen as too long;
 Many of those who received healthcare abroad made use of family connections, which
seemed a significant driver. Those who did not have family connections appeared to
undertake research successfully via the internet;
 Reasons for seeking healthcare abroad were associated with waiting times, receipt of
what they perceived to be better quality care, or receipt of private health care in a
country where costs were lower than in the UK;
 Those who sought private healthcare in the UK were concerned mostly about waiting
times;
 The majority of participants might consider seeking healthcare abroad for similar reasons
for planned diagnostic tests or minor surgery, or to receive treatments that were not
available in the UK;
 Participants were not wholesale in favour of seeking healthcare abroad: there were
concerns about what to do about aftercare and complications. Reservations were
expressed about going abroad for major surgery;
 Many had received dental care successfully abroad, both planned and urgent.
Interestingly, the group was divided as to whether they would seek dental care abroad;
aftercare was again a concern;
 Many said they never thought of seeking healthcare abroad, but might consider it now,
given their increased awareness of the possibility as a result of participating in the
project.
Section 5
35
5.1
INTRODUCTION
Focus groups have been held with a sample of individuals who participated in the public
survey and whom had either received healthcare abroad, or who had expressed an interest
in travelling abroad for healthcare. The purpose of the Focus Groups was to investigate in
more depth the views of people about receiving healthcare abroad, and under what
circumstances they would wish to seek such care.
5.2
PROCESS FOR RECRUITMENT AND MANAGEMENT
Potential participants were recruited by QA Research, who had arranged and undertaken the
Public Survey. Two groups of individuals were identified: those who had received healthcare
abroad and those who had expressed an interest in travelling abroad for healthcare.
Those who were had received Healthcare abroad were defined as those who had provided a
positive response to the following questions in the Public Survey:
Q2: Those who had received planned healthcare whilst living abroad;
Q4: Those who had received unplanned (emergency) healthcare whilst travelling abroad;
Q11:Those that have received planned healthcare in a European country in the past 12
months
Q18: Those who had travelled abroad (anywhere outside the UK) with the primary intention
of receiving planned healthcare. Including those who had travelled abroad in order for their
child to receive treatment.
Following de-duplication (where individuals who may have provided more than one
response), we were left with 32 individuals. Broken down as follows (note: age-band relates
to age and gender of parent, not child).
Age band
Gender
Female
Male
Grand Total
20-29
30-39
2
0
2
40-49
3
0
3
50-59
4
3
7
60-69
6
1
7
Grand
Total
70-79
3
7
10
1
2
3
19
13
32
Those who had considered receiving Healthcare abroad were selected from those
individuals who had provided a positive response to the following question in the Public
Survey:
Q36: Have you previously considered travelling abroad to receive healthcare (before
respondents were told about the possibility of receiving healthcare abroad through the NHS).
Section 5
36
Following de-duplication (where individuals who may have responded to going abroad to
receive unplanned healthcare were removed), we were left with 42 individuals. Broken down
as follows:
Age band
Gender
Female
Male
Grand Total
20-29
30-39
1
1
2
40-49
2
3
5
50-59
11
1
12
60-69
7
3
10
Grand
Total
70-79
6
6
12
0
1
1
27
15
42
All of those individuals who had received healthcare abroad were contacted. They were sent
a letter prior to being contacted direct by telephone, with details of the groups and why they
were being asked to take part in the groups (although this was done in waves to minimise
the possibility of over recruitment). For those who had considered receiving healthcare
abroad, some individuals were not asked to take part in the groups, as the quota had been
filled.
Out of the 32 individuals contacted, who had received healthcare abroad, nine accepted,
one of whom later dropped out, six could not be contacted, and 17 refused. Out of the 42
individuals who had considered healthcare abroad, 17 accepted, of which five later dropped
out, six could not be contacted and four refused. Fifteen were not contacted.
Those who wished to participate were given more details of the Groups, including topics for
discussion. Participants are only known to QA, with whom they agreed a name or
pseudonym which they used in the Focus Group. Participants were sent a gift voucher as a
thank you for participating.
All groups were managed through a free phone conference call, facilitated by a member of
the research team who has a clinical background, and is experienced at working with patient
focus groups, and with giving patients information about treatments. The calls were recorded
to aid with subsequent analysis. Participants were informed of this when invited to join the
group.
We ran four focus groups, one in the week of 12th and three in the week of 19th April.
5.3
ANALYSIS OF PARTICIPANTS
Twenty two people were recruited. One person informed QA prior to the Group that they
could not attend and were replaced. Two people did not call in on the appointed day/time.
Twenty people finally participated in the Groups.
Participant details are shown in table 5.1
Section 5
37
Table 5.1
Participants by group topic
Group topic
Received
healthcare abroad
Afternoon group
3
Evening group
5
Total participants
8
Considered
healthcare abroad
6
6
12
Total
participants
9
11
20
The age and gender breakdown are shown in tables 5.2 and 5.3.
Table 5.2
Participants by age and by group topic
Age group
20-29
30-39
40-49
50-59
Received healthcare
0
3
1
3
abroad
Considered
1
1
4
2
healthcare abroad
Total participants
1
5
5
5
60-69
1
Total
8
4
12
5
20
Table 5.3
Participants by gender and by group topic
Gender
Male
Female
Total
Received
healthcare
1
7
8
abroad
Considered healthcare
3
9
12
abroad
Total participants
4
16
20
Table 5.4 shows the geographical distribution of participants.
Table 5.4
Geographical distribution of participants
Geographical location
Number of participants
Scotland
1
North of England
1
Midlands and East of England
4
London
1
South and South East of England
9
South West of England
4
Total
20
The age structure of those that have received healthcare abroad is slightly younger than the
group that considered healthcare abroad. The age structure of those receiving healthcare
abroad in our survey was younger, as they included those working abroad and on holiday as
well as those that had chosen to travel abroad. A greater proportion of women have
participated, and the South of England has a higher representation. Therefore the
participants in the Focus Groups are not representative of our Public Survey sample.
However, we have no evidence to suggest that these apparent biases in the sample will
affect the opinions and the information that we have derived from the Group discussions.
Section 5
38
5.4
TOPICS FOR DISCUSSION
Although we expected that the focus groups would discuss issues that mattered to the
participants, we drew up a list of topics that we wanted the group to discuss. Those for the
groups who have received healthcare abroad are shown in box 5.1.
At the beginning of the Group, participants were asked to introduce themselves (using their
chosen name) and briefly explain what treatment they (or their family member received),
where they received their healthcare, and why they received your healthcare abroad (rather
than in the UK). They were also asked to describe who paid for the healthcare (whether it
was NHS funded, whether they paid, or whether their insurance or employer insurance paid).
Box 5.1
Topics for discussion in Focus Groups of those who have received
healthcare abroad







We would like to know what your experience of the treatment was like, for example what
did you feel about the quality of your treatment, of the staff and the facility.
We would like to know how did you feel about the process of obtaining your healthcare,
for example, finding out about the facility and the surgeon or physician, communicating
with them before and after the treatment, and whether you have had any on-going
contact. Who helped you find your way through the process?
Did you have any subsequent problems or complaints, and how did you resolve these?
What was your experience like re-entering the NHS? Did you encounter hostility, or have
any problems, for example from your GP, dentist or other clinicians?
How did your experience of healthcare abroad compare to treatment you have received
in the UK, and in the NHS or other private facilities.
Given a choice, would you seek healthcare treatment abroad again? Why and under
what circumstances. What might the barriers be?
Is there anything else you want to tell us…?
The topics for discussion for participants in those groups who have expressed an interest in
receiving healthcare abroad are shown in box 5.2.
At the beginning of the Focus Group session, participants again were asked to briefly
introduce themselves and describe what hospital (inpatient or outpatient) treatment or what
dental treatment they (or a family member) have received in the UK. They were also asked
whether the healthcare or dental care was under the NHS or in a private facility, and if in a
private facility, who paid for the healthcare (whether it was NHS funded, whether they paid,
or whether their insurance or employer insurance paid).
Section 5
39
Box 5.2
Topics for discussion in Focus Group of those who have expressed
interest in receiving healthcare abroad.








We would like to know what your experience of the treatment was like, for example what
did you feel about the quality of your treatment, of the staff and the facility.
You have expressed an interest in receiving healthcare abroad. For what conditions
would you consider travelling abroad for healthcare, and under what circumstances?
What concerns do you have about the NHS, or private healthcare in the UK that would
lead you to consider healthcare abroad.
Would you seek healthcare funded by the NHS or funded by insurance or privately.
We would like to know the experience of you/your family in receiving dental care. Are
you registered with an NHS dentist, or a private dentist, and did you have any problems
in finding a dentist. Have you considered going abroad for dental care?
How and where would you find out about getting healthcare abroad, including dental
care?
Have you discussed receipt of planned healthcare, including dental care, with your GP or
dentist, with your healthcare commissioner/pct, or with another person or organisation?
Have you discussed with friends or family. What information did you receive and what
was their advice.
Is there anything else you want to tell us…?
5.5
FINDINGS
5.5.1
Healthcare received abroad
Although, according to our survey information, eight of the participants (or a relative) had
received health care abroad, we discovered that a further three people had also received
care abroad, one of whom also bought their medication in mainland Europe.
Table 5.5 summarises the health care received abroad by our focus group participants26.
26
NB The names of all participants have been changed from those used in their Focus Groups to ensure
anonymity: it is possible that individuals used their own forenames for Groups.
Section 5
40
Table 5.5
Participant
Summary of treatment received abroad by focus group participants
Country where Urgent/
Funding
Condition
healthcare
Planned
treated
received
care
Dennis
Hungary
Planned
Family live in Hungary: Ante-natal 3-d
(daughter –inon their health care scan
law)
scheme
Tina
Netherlands
Planned
Husband in military: Obstetric care
free
Rosemary
South Africa
Planned
Private
Facial cosmetic
surgery
Lyn
Morocco
Urgent
Travel insurance
Reaction
to
antibiotics
Jill
US
Planned
Family live in US: Dental
private
extraction
Wanda
and Spain
Planned
Family live in Spain: Annual
children
on their health care checkups for her
scheme
and children
Josie
Tunisia
Urgent
Company insurance
Crohn’s Disease
Planned
Private
Dental bridge
Nancy
France
Planned/
Family live in France: Chronic
back
Ongoing
on their health care pain
scheme
Carol
Brazil
Urgent
Travel insurance
Septic
insect
bites
Doug
Spain
Planned
Private
Purchase
medication
Wife
Cyprus
Urgent
Travel insurance
Food poisoning
Jessica
South Africa
Urgent
Travel insurance
Dental care
The majority of conditions described above are unsurprising, including two obstetric cases,
three dental cases, and problems experienced on holiday. Eight of the participants had
chosen to travel abroad for healthcare, including two for dental care. Of interest is the
number that use healthcare in the country where their family live through their healthcare
arrangements.
5.5.2
Healthcare received in the UK health care
All 20 participants had experience of UK NHS healthcare, ranging from ongoing treatment
over many years for serious conditions usually in specialist facilities, to occasional use of
A&E facilities, minor operations and visits to GP practices. They also had experiences of
close relatives’ receiving healthcare. Seven of our participants had healthcare insurance
and had used private healthcare facilities in the UK. One also had a child whose grommets
were inserted privately, to avoid a waiting list; “he was very deaf, so we paid to avoid a long
waiting list”. Two more paid for surgery in the UK, using bank loans. One chose not to have
the procedure on the NHS, although the plastic surgery required was a by-product of their
ongoing NHS treatment: ”I didn’t want to burden the NHS…it was cosmetic and I didn’t need
it…so I paid for it…I was selfish”. A second described how her husband needed an operation
Section 5
41
on his spine, but faced with an 18 month waiting list and the need for fast treatment (he ran
his own business and could not afford to be incapacitated); they too took out a loan to pay
for private care. The operation was done within two weeks.
5.5.3
Comparative views of experiences.
Experiences
Participants were asked their views on their healthcare experiences. All were very positive
about their experiences of their healthcare abroad. They used words such as excellent,
brilliant, amazing and superb. They all spoke of excellent facilities, staff who could speak
English well, and well organised processes. Doug, whose wife was rushed to (a private)
hospital by a doctor, with food poisoning was fulsome in his praise “the doctor took her in his
car…they treated her like a queen”. Tina, who had a baby in a hospital in the Netherlands,
said that “the actual labour was long and awful, but the care received was amazing and the
aftercare was excellent”. She also commented that gas and air and pain relief appears not to
be the norm in the Netherlands for child birth, so she did not receive any. She also
commented that, “although the care in the Netherlands was brilliant, they would talk between
themselves in Dutch and I didn’t know what was going on”. Lyn commented that her care in
a hospital in Marrakesh was “excellent [in a] well equipped clean hospital”. These
experiences seemed to apply to planned and emergency care. Similar comments were
made about private care received in the UK. None reported having clinical problems,
problems with aftercare, or having to make a complaint about any aspect of their care.
Experiences of NHS care varied dramatically from the excellent to the poor.
Tessa, who has had 26 years of medical care, stated that “I have had nothing but fantastic
treatment from the NHS – maybe it depends where I live. Have a fantastic local hospital”.
Harriet, who had a hip replacement in an NHS-run military hospital said that “her operation
went OK”; although she felt that the military staff were better than the NHS staff. Doug,
whose granddaughter has chronic lung disease, praised the care received in the paediatric
ICU at his local hospital “[it] was fabulous”. Rosemary had gynaecological surgery, which
she “couldn’t fault”, One of her children, having had grommets inserted privately, had them
done a second time, but in the NHS. She said that “the second time had it done; it was done
quickly on the NHS. [we had] no complaints about the length of wait, nor the treatment –
they were all excellent”. Finally, Tanya who was happy with the care she received did
comment “my only concern was that they tried to get me out of hospital too quickly…I wasn’t
up to coming home so quickly, as I only had my mother at home and didn’t think she could
look after me properly. I asked to stay another day and they said no”.
On the other hand, Doug, who has had multiple orthopaedic operations, and who is waiting
for a further hip replacement said “the local hospital is disgusting...I am dreading going into
it”. Jessica’s husband, who had a neurological problem, went to a local hospital for an
infection “[he was] treated abysmally. I threatened to take him and his bed home, he was
treated so badly”.
Section 5
42
John, who is being treated for cancer, contrasted the care he received at his specialist
hospital: “the facilities are brilliant…the staff are brilliant, any problems they will console me,
they help me with anything” with care at his local hospital “the staff are rushed at [name of
hospital]; they don’t have time to tell you what’s going on”. However, he is full of praise for
his local pain management team, and the local hospice.
Views on the state of the NHS also varied. Participants mostly commented on three aspects:
the staffing, the level of cleanliness and related infections, and waiting times.
Views about staffing
Participants expressed concern at what they perceived to be “the lack of professionalism in
nursing”. They believed that nurses did not seem to care for their patients, that they were
very rushed and did not spend enough time, or forgot patients. One commented that her
husband “was allowed to fall out of bed and broke his nose…I felt the nurses did not care”,
another that “they don’t care now...a different group of people go into nursing now…nursing
standards have dropped” (this participant had been a nurse). ”. Vicky commented that, after
having surgery, “I felt the nurses were lazy. One evening I hobbled out and found the nurse
on duty ordering her Christmas presents on-line….they say they will see you in a minute and
you have to wait….I had to phone a friend to get them to bring up paracetemol from the local
chemist”.
She also believed that “there are two standards...specialist nursing is
better...since we have changed nursing skills and how they are trained…people may be in
nursing for the money…they may not want to be in nursing for love”. Jessica explained that
she had told the staff that her husband was very ill, “they wouldn’t let me stay with him. He
needed 24 hour nursing care and they couldn’t or wouldn’t give it to him, they were too busy.
I took him home the next day; I wouldn’t let him stay there.”.
Not all participants were so critical; many felt that staffing levels appeared low, and that
nurses were doing their best but were very rushed and stressed. For example, Rosemary
observed that, “the staff were stretched to the limit...if there was anything out of the ordinary,
like a diabetic lady on my ward with major problems...they dedicated their time to her. So if
they had another major problem, they would have been very stretched”. Many commented
on the role of matrons, and how matrons used to ensure quality care on wards. As Doug
believed, “when matrons were scrapped, care declined…now matrons are back, it may
improve”.
Those who had received healthcare abroad or in private hospitals generally compared
unfavourably the level of nursing care received in NHS facilities with those in private
hospitals or those abroad. However, they did mostly acknowledge that, if you paid for
healthcare, you probably did get more attention to detail.
Few commented about doctors, most comments about senior medical staff were favourable,
believing that medical care in the NHS and the private sector were comparable. As one
participant observed, “they were probably the same doctors”. Graham related the
experiences of not being seen by his consultant in the NHS. He normally receives private
healthcare (having healthcare insurance), but began receiving care for his diabetes two
Section 5
43
years ago in the NHS, as his insurance does not cover chronic conditions. He has been to
the eye clinic of his local hospital numerous times. Once he was seen “by a person shipped
in from Cyprus who couldn’t speak English”. On a second occasion, he was seen by a doctor
from Greece. “Because it was late in the afternoon, I saw her stand in front of an elderly
patient…and demanded that the sister sign her pay sheet, because the last time she worked
after 4.30 she didn’t get paid. I am not impressed by their view of a caring profession”.
Another participant expressed concern about the quality of care he had received from a
junior doctor whom he did not think was competent to draw fluid from his knee, as he
seemed to making a mess of the procedure.
Participants also had positive and negative comments about GPs. Many were very happy
with their GP practice. Josie said “I can’t knock my GP…fantastic...a big practice. I have
never had a complaint about my GPs, but it’s like a lottery, is good and bad.” Others were
less complementary; for example “I call my doctor Mr Penicillin as that is all he offers”.
Wanda, on explaining why she seeks health care in Spain described the problems she has
had with persuading her GP that her son’s illnesses (respiratory complaints and headaches)
were serious: “My GP says ‘Oh he’s growing...nothing to worry about…come back in six
months and let me know’. I can’t wait six months. It was the same when his asthma
started…I don’t understand why it is so difficult to see a specialist. You almost have to go on
bended knee”. Nancy, who has received healthcare in France, said “I am reluctant to go to
the GP …they usually offer a prescription…what’s the point?”
Views about cleanliness
Those that had received private healthcare or healthcare abroad were normally fulsome in
their praise of the facilities and the cleanliness.
Participants were mostly very concerned at the level of cleanliness in NHS hospitals. Many
had stories about friends or relatives who had caught hospital acquired infections. Doug,
who has used his local hospital for many years, and also worked for the NHS, believed that
“cleanliness seemed to go down when they started to go out to tender...when a private
company do it, they are not properly trained and paid minimal wages. If their own team did it
– it’s about pride. Now it’s all about money. If paid cleaners more...it would be better...private
companies don’t deliver”. Rosemary said “you hear about MRSA constantly…it’s the only
thing that bothers me”. Daryl commented, “I have grave reservations about healthcare in
NHS. A friend went in for a minor operation (hernia)…they caught MRSA, and have been in
and out of hospital for 12 months. It’s a disgraceful way to treat someone”. Doug described
seeing hair in the bath, and explained how a friend went into hospital for a minor operation,
caught an infection and died. “I have heard that hospitals abroad are much cleaner”. Wanda,
who goes to Spain regularly to receive care believes that “the hospitals are cleaner in Spain
…they are quite horrendous in the UK”.
Comments were also made about the buildings and facilities, for example, “there was more
scrap metal in my ward than in a tinker’s yard (frames and wheelchairs etc)…there were six
of us in the room trying to walk”. Vicky believed “if you go to the private wing of your local
hospital, it’s like going from third world to a posh hotel”. Tammy said, commenting on the
Section 5
44
private hospital in which she received some tests, “The private hospital looked cleaner – it
looked more like a hotel. The reception was good, the bed space was lovely”. Graham, of
his local hospital said “it is 30 years old and is falling down…it is not mistreated, but just
don’t think people care down there. If the building is falling down, what chances have the
patients?”
Views about waiting times
Our participants had all experienced receiving urgent care and planned care. Urgent care in
the NHS was both complemented and criticised. Ambulance services were seen in a positive
light, no-one commented on having to wait for an ambulance to arrive, for example “my
husband collapsed and I called an ambulance. It arrived quickly”.
A&E services were not so well received. For example, Tanya explained how, as a result of
living in a village, she is some 30 miles for an A&E department: “My mother broke her wrist
recently…had to travel 30 miles to get an x-ray as the local hospital doesn’t do A&E. [X
hospital] couldn’t find a break in her wrist and she is now waiting two weeks for an MRI scan.
But her wrist is swelling up like a balloon”. Other comments included: “I am unhappy about
A&E, I have waited a long time in A&E” or “Our local A&E is a place for drunken people to
go...a lot is about the clientele and the situation”.
A common reason for seeking private healthcare in the UK was the waiting times for
diagnostic testing or surgery. Tammy explained, “I had had a liver function test and there
was a problem. They wanted me to see a specialist. There was a six to eight week wait for a
proper scan on my liver, so I went private. I was so worried I opted for private...The results
were OK”.
Other participants were more sanguine about waiting times. Tessa described how she had
to wait for her surgery, “I had to wait more than 12 weeks for one lot of surgery…it was
reasonable, I was not at death’s door. The only time I had to wait was when I needed two
separate procedures under a single anaesthetic…I had to wait for two surgeons to be
available together and I waited six months. I was still happy with this, I had excellent care”.
5.5.4
Dental care
Participants were asked to describe their experiences in respect of dental care both in the
UK (NHS and private) and abroad. Some participants had dental plans, and others received
NHS and private care, or solely NHS care. Some had minimal experience of dental care. As
with other aspects of their healthcare experiences, experiences of dental care were very
mixed. As seen in table 5.5, three participants received dental care abroad.
Jill, whose family lives in the US, has lived in the UK for 12 years, broke her tooth and could
not find a dentist. “I went to see the GP and he said good luck, it is very difficult to find a
dentist. He gave me antibiotics. Where the tooth was broken, he said you would be OK. I
was not happy with this and I went door to door to local dentists. One that I was happy about
said I could not have an appointment as they were fully booked. I had made plans to go back
Section 5
45
to the US and via my family set up an appointment with a dentist in the US. The dentist
pulled out the broken tooth and said I shouldn’t have left the tooth in”. Jill paid for her dental
care privately. She explained further, “I went back to the GP for something else. He
remembered me and gave me the name of a dentist. I went down and met the dentist who
took me on as a patient. He told me he will see me every six months. After six months
nothing happened…. After one year, nothing happened. So I went back and asked what I
should do. He said, ‘we are so far behind, come in and make an appointment’ He seems OK,
a clean little office, I have no complaints, but he must be inundated with patients”.
Josie went to Tunisia on holiday and whilst there had a dental bridge fitted, which would
have cost her £3,000 in the UK, but cost £300 in Tunisia. She commented, “it wasn’t dirty...it
wasn’t modern…but it was OK. They knew what they were doing and did a good job. I would
go back”. Like Jill, Josie paid privately for the dental care. Jessica needed emergency dental
care when she was on holiday in South Africa. She commented, “It was fantastic. They even
sent me digital images of my tooth to my home address…My dentist doesn’t even have a
digital camera. I would definitely go to South Africa for dental work. I had a big root canal
filling...it was only £79, it would have been several hundred in the UK”.
Carol went on the internet to find an NHS dentist. Fortunately a new dentist advertised for
patients locally, and she was able to get registered. She was unhappy with her previous
dentist, “I had treatment with one dentist, which led to having the top set of teeth removed. It
was painful...it was done in an uncaring and unfeeling way. I was frightened of going to the
dentist. The current one treats you as a person, not just as a mouth. I never thought of going
abroad”.
5.5.5
Reasons for seeking healthcare abroad or in the private sector in the UK
Here we are only focusing on those participants who planned to receive health care abroad
or in the private sector. The reasons given were very similar, relating to personal
circumstances, normally having family in another country, problems with accessing care in
the NHS, for example due to longer waiting times, or with cost.
Two participants described experiences with obstetric care. Dennis’s daughter-in law went to
Hungary to get a 3-D scan. She prefers the healthcare in Hungary, and can access it easily
having family living there. He said, “she was not impressed by the experience of the birth of
her child at the NHS hospital”. Tina’s husband was in the military, and she had her first baby
in the Netherlands, and the second in the UK. Jill described receiving dental care in the US,
which was arranged by her family, using a dentist known to them, because she could not
find a local dentist that she was happy with. Wanda and Nancy have both received
healthcare through their families in Spain and France respectively, in part they were not
happy with the care being received in the UK, and also because they could benefit from the
healthcare arrangements of their family.
Rosemary travelled to South Africa for cosmetic surgery, which would not have been
available on the NHS. The cost in South Africa was much cheaper than the equivalent
cosmetic surgery in the UK. She chose South Africa, because she had family there, a cousin
Section 5
46
had undergone similar surgery and recommended the consultant. They also had a friend
who needed reconstructive surgery following a car accident who also received care from this
consultant. Although the consultant came with recommendations, Rosemary researched him
and the hospital on the internet. She explained “the literature tells you what surgeons should
ask you…the consultant gave me all the information I needed without promoting”. She was
very happy with all aspects of her treatment.
Doug buys his medication in Spain. Because he works, he has to pay for prescriptions and
he has calculated that it is cheaper to buy large supplies when on holiday there, or he asks
friends to bring them back. He explained, “the GP knows, it is on my record…he can’t stop
me”.
The prime reason for those who sought private healthcare in the UK was waiting time.
Daryl’s husband needed surgery on his spine, and Dennis’s grandson needed grommets
inserting. For both, a long wait was unacceptable to them. Tessa paid for healthcare
privately in the UK, as she did not want to burden the NHS, and she wanted to have her
reconstructive surgery quickly.
5.5.6
For what reasons would you go abroad?
Participants were asked for what conditions they would seek healthcare abroad. Those who
had been treated abroad, whether planned or emergency, would go back. They were
confident about the care, and were pleased with the facilities, the staff and the outcomes.
Those who had received private health care in the UK were more hesitant, although, many
said they would go abroad for surgery or treatment, for example if new drugs were available.
Many participants cited their concerns about potential problems with aftercare: where would
they receive this care, how would they manage abroad immediately post surgery, and what
would happen if there were complication? Comments included, “I thought about going
abroad for my operation, it would have been £3,000 cheaper, but I didn’t want to be on my
own”. Others had concerns about potential problems with the language.
Tessa explained, “I am not in a position to always have private healthcare…I don’t have
insurance...it was once-off. But if it was another one-off but with a long waiting list, because I
work, I would consider going abroad for the operation”.
John, who has received extensive cancer treatment, would be prepared to go abroad for
treatment “if I didn’t think I was getting the right treatment here, or was able to get the right
treatment here. [my cancer] is very rare so it is a bit hit and miss…so I would be prepared to
go abroad to try new treatment”.
The relationship between paying for healthcare and the quality received was clear to all, as
one participant commented, “if you go abroad, you are paying for care, and whenever you
pay you get better treatment”.
Interestingly, despite many negative comments about perceived problems in the NHS,
participants without private insurance (and some with) also said they were happy being
Section 5
47
managed in the NHS, particularly for specialist care. Comments included “Doctors in the
NHS are happy to refer you to other doctors specialising in the field. I am happy inside the
NHS”; “Macmillan nurses are brilliant and highly skilled” and “I have nothing to complain
about…the local hospital is clean…when I have an appointment it is fine, it is the waiting”.
Participants also recognised that there could be problems with private healthcare, or
healthcare abroad. For example, Vicky described, “When I had my second knee operation
done, the lady in the bed next to me had had a knee replacement in Eastern Europe and
had to have it repaired. She was not happy about it. You think you will get the best care
when you go abroad, but this lady has not”. Josie commented “I thought you were not
supposed to fly after surgery, yet you would have to if you went abroad...that’s probably why
you tag on a holiday at the end. In the US you can do a holiday and have a gastric
band…it’s a whole package. I wouldn’t chance it…I’ll stick with weightwatchers”.
Rosemary, who had received surgery in South Africa said, “I am considering having more
cosmetic surgery (a tummy tuck which is more invasive). I would prefer to have it done in the
UK but it would be more expensive, but if it went wrong in South Africa it would cost a
fortune. I have to weigh this up. If it was major surgery I would have it done in a private
hospital in the UK and would do a lot of research. I would only seek planned cosmetic minor
surgery abroad, but only in South Africa. I wouldn’t go anywhere like Romania”.
When asked about receipt of dental care abroad, several participants explicitly stated that
they would not want to go. Daryl, however, had researched going abroad to Austria or
Germany for a tooth implant, the need for which had been caused by a “problematic implant
from a poor dentist. I contacted the PCT…I was thinking about suing him…The PCT didn’t
support this. I looked at facilities on-line. The information was clear. The price was half and
there was aftercare”.
Finally, several participants commented that they felt they had paid taxes for many years,
and should be able to have NHS care, and therefore should not be thinking about going
abroad. Several had commented during the course of the group sessions that they had not
thought about going abroad for healthcare, but might do so now. A few, having heard more
about the potential for receipt of health care abroad, would not just now consider this an
option, but wanted to know more about it, for example, “I have heard you can get your heart
operation in Belgium…how do you apply for this if you are on the waiting list…I would be
interested in this. ..I don’t know how to go about this”.
Section 5
48
Section 6:
Survey of NHS Commissioners
Key findings
 Our survey of commissioners had a low response rate. This is in itself evidence of
the low priority given by commissioners to patients requesting planned care
overseas.
 Despite the low number of responses, there were common themes within the
responses we did receive: The majority of commissioners understand that there are
two parallel routes for funding planned healthcare abroad, but do not necessarily
consider the implications for following one route rather than another
 The majority of commissioners have processes in place for managing requests and
authorisations.
 As evidenced by the small numbers of patients who receive planned healthcare
abroad by either route commissioners see these patients as exceptional and
different. Most have some form of ‘Exception Panels’ whereby requests are
reviewed.
 None of the responding PCTs or Health Boards indicated they actively discouraged
or dismissed cross-border requests out of hand. However there was no evidence that
PCTs were actively supporting or encouraging people to exercise their rights in this
area.
 Most commissioners do not have leaflets or information for patients, and frequently
refer patients to the DH web site or to PALS. Some commissioners referred to
Commissioning Strategies on their web sites.
 Our analysis of the data from commissioners suggests a range of 0 requests for
authorisation that they have ever received to around 20, with the maximum number
of authorisations being around 8 (this is supported by our analysis of the DWP data).
 The very small number of authorisations under article 56 suggests that this is not a
route through which many patients are funded. This may reflect unwillingness on the
part of patients to pay in advance of receipt of care, an unwillingness of
commissioners to pay for healthcare retrospectively for which there may not have
been prior authorisation, or the difficulties faced by patients in receiving information
and going down this route.
 Only around half of respondents were able to describe the upcoming new directive
and only around 10% in any detail. This lack of knowledge is not a positive indicator
for preparedness for the directive.
Section 6
49
6.1
INTRODUCTION
Our survey of commissioners sought to collect information about:


The processes that Commissioners have in place to receive, process and authorise
requests for planned treatment overseas
The patients who have requested and/or received treatment overseas. We are
particularly interested in receiving information on treatment undertaken under article
56, as we have no other mechanisms for obtaining this information.
The survey was designed using our literature review and discussions with the DH It was
amended following our data collection at DWP and further discussions with the DH (a copy
of the survey used is given in the technical appendix).
A letter inviting commissioners to participate in the survey, together with a copy of the
electronic survey and a briefing about the study was emailed to directors (or equivalent) of
acute commissioning at all PCTs in England, and Health Boards or the equivalent in
Scotland, Wales and Northern Ireland. Commissioners were able to return an electronic
version of the survey, complete a web version, or post or fax a completed hard copy.
The survey focused on three broad areas:



Baseline information about awareness and planned and actual processes in health
boards and PCTs;
Information about patients who had received cross border healthcare
How the respondent can help during the next steps in the study, in particular,
whether they are:
o
Interested in participating in a focus group, or be a case study site
o
Prepared to participate in a brief follow-up telephone interview
Commissioners were encouraged to send any documents detailing procedures or guidance
describing the processes and/or any reports that that have been drafted for their Boards or
Senior Management Groups. Focus groups and case studies were designed to elicit
additional and more in-depth information about processes, barriers and problems, and good
practice. In the event, although 10 respondents expressed an initial interest in participating in
a focus groups, it was not possible to organise these groups, as no participants were able to
commit to specific dates or time offered. However, five of these respondents did offer to be
case study sites, offers which were accepted. The case study analysis is given in section 7
of this report.
We received and analysed responses from 38 commissioners, 35 of which are from English
PCTs, two from Wales and one from Scotland. Thus the response rate for English PCTs was
25%27 despite sending our first tranche of emails in early December. We had significant
problems with the response rate, and adopted several approaches to increasing this,
27
Our denominator is 151, as one PCT referred us to a second for their response.
Section 6
50
including multiple emails and phoning all non-responding PCTs and speaking to the relevant
person. We believe that reasons for the low response rate include:


The subject matter being very low priority for most PCTs
Identifying the correct person in a PCT (confirmed by many of the responses to our
follow-up phone calls, described below)
PCTs changing email addresses: we have had frequent bounce backs

Responses to our phone calls included:

Original contact having left the organisation, and being provided with name of new
contact, with name of alternative, or being told there is no replacement;
No response, but left messages with co-workers, or on answer machines
Explanations why surveys could not be completed;
No response to phone call and no opportunity to leave message



Although many people we spoke to gave us alternative details, or told us to re-send surveys
with promises of completion, the response rate was still low. Whilst we suspect the lack of
interest in responding was due to many areas dealing with few requests in this area, it is
interesting to note that the PCTs with the highest number of E112s authorised did not,
despite our best efforts, complete surveys. One PCT, with seven E112s authorised told us
that they “did not feel equipped to deal with it and so won’t be returning it”.
6.2
6.2.1
ANALYSIS OF RESPONSES
Level of knowledge and readiness
36 (95%) of respondents are aware of the requirements for authorisation of health care
abroad under regulation 1408/71 (using form E112), and 32 (84%) are aware of the
requirements for authorisation under Article 56. All but four gave an explanation of their
awareness of processes re E112 and all but five gave an explanation re article 56. The
explanations were mostly factual, often referencing their guidelines: “E112 entitles patients
to treatment in the state-funded section of another EEA country and Switzerland”, or “We
follow the guidance on the NHS Choices website regarding E112 applications”. An example
of a typical longer explanation in respect of the E112 is:
“The E112 process entitles patients to be treated in the state-funded sector of another
European country (although not all of them). Treatment is provided under the same terms
and conditions as residents of that country. The commissioner has to be assured that a
number of criteria are met: - A UK NHS consultant has recommended in writing that the
patient needs to be treated in the other EU country, and that a full clinical assessment has
been carried out to demonstrate that the treatment will meet your specific needs. - The
costs of sending the patient abroad for treatment are justifiable - The treatment is available
under the other country’s state health scheme. - The treatment is available under the other
country’s state health scheme. - The patient is entitled to treatment under the NHS.”
Section 6
51
Many of the responses were very similar, and many referred to the DH or NHS Choices
websites. The majority of respondents understood the nuances of the difference between
E112 and article 56, especially in respect of the levels of funding that can be offered.
The majority of commissioners responding to the survey understand that there are two
parallel routes for funding planned healthcare abroad. However, a minority (16%) did not
fully understand all requirements for authorising treatment abroad. If the same percentage
of all PCTs do not understand requirements – which is a conservative estimate as it is
feasible that those who did not respond to the survey are more likely to not understand
processes – it means that at least 20 PCTs do not fully understand processes.
Finally, 23 (61%) of respondents are aware of the proposed directive from the EU in respect
of cross border health care. This is a lower figure than are aware of the parallel routes for
authorisation and funding. Nineteen gave a brief explanation. Several referred to the DH
website, or indicated that they were aware that the EU was proposing a new directive but
gave no further explanation, and four respondents gave a more detailed explanation. One
respondent stated they had participated in the consultation on wording.
32 (84%) of respondents told us that they had processes in place for the authorisation of the
planned receipt of healthcare using form E112 or Article 56, with only four telling us they did
not. 34 respondents gave an explanation of their processes (or lack of them), and several
attached documents which described these processes. We specifically asked respondents to
describe briefly their processes, indicate whether they had a panel or group that reviews
applications, and who takes responsibility for applications, and whether there were quality
audits in place. We did not request information on the accessibility of these processes,
although from the qualitative site visit interviews, and the mystery shopping, we discovered
that the processes and guidelines were mostly for internal use. The processes did not
necessarily refer to the regulations but normally described the steps by which such a request
was considered and authorised.
19 PCTs described processes involving the application being considered by a panel,
examples of the panel name being the Exceptional Circumstances Panel, the Individual
Patient Panel, the Individual Patient Commissioning Panel, the Exceptional Treatments
Group or the Urgent Individual Funding Requests Panel. Other processes cited by five PCTs
did not refer to Panels but to Processes, for example, the PCT Individual Funding Request
process. Two PCTs described processes involving the case being considered in the first
instance by a Director of Commissioning or Associate Medical Director. Finally, other
respondents cited general policies: one cited a policy drafted by the Strategic Health
Authority’s Strategic Commissioning Group, another a Joint Commissioning Policy, a third
“has a team in place dealing with individual requests”, and a fourth that they have a policy
which is not yet finalised. The responses gave us insights into how PCTs normally
considered these requests, which we followed up in more detail at the site visits.
Section 6
52
6.2.2
Guidance offered by commissioners
Table 6.1 shows the responses to our question on what guidance does the commissioner
offer to patients who request receipt of health care overseas, whether potentially being paid
for by the PCT/DWP or privately by the patient or health insurance. Commissioners could
provide multiple responses.
Table 6.1
Guidance offered by commissioners to patients
Guidance offered to patient
Guidance on funding
Guidance on eligibility
Guidance on the appeals procedure
Guidance on pathways of care
Guidance on associated costs, such as travel
Guidance on selection of healthcare provider
Guidance on follow-up to care received
Guidance on what to do if patient has complications after treatment
Guidance on what to do if patient wants to make complaint
Refer patient on to another organisation which does provide guidance
Never been approached
Do not offer guidance
Don’t know
No (%) respondents
offering guidance
23 (61%)
24 (63%)
17 (45%)
5 (13%)
11 (29%)
3 (8%)
4 (11%)
4 (11%)
8 (21%)
5 (13%)
3 (8%)
3 (8%)
4 (11%)
Responses given by those that referred patients to another organisation included the DH
website, the local PALS service, a referring trust, or the local SHA.
Commissioners were asked in what format they provide guidance: 23 (61%) told us verbal –
by telephone; 8 (21%) verbal – face to face; 17 (45%) provided written guidance; and 6
(16%) that the guidance was on the commissioner website. 24 briefly described the
guidance, and by whom it was offered. Box 6.1 gives examples of the guidance offered.
Guidance can be offered by a Commissioning Manager, the PALS manager, or members of
the Exception Treatment Team (or equivalent). From the responses given in box 6.1, we do
not know how off-putting was the guidance, and whether potential patients, having received
the guidance, did not proceed, because of barriers (implicit or explicit) put in place. However,
again, these responses gave us insights that we were able to follow up in the case study site
visits and mystery shopping, for example, how accurate was the information, whether it
conformed to regulations, and how receptive and accommodating were commissioners
Section 6
53
Box 6.1
Examples of guidance offered

A commissioner would explain the process set out above and ascertain that the
patient is registered with a local PCT for eligibility reasons and advise that
associated costs such as travel would not be covered;
Guidance is often given by the Head of Contracting to explain the process that
needs to be undertaken in order for patients to have their funding approved.
Individuals are shown or talked through the National guidance and the internet
links are given to patients so that they can understand that it is a national process;
If the patient telephoned the office, guidance is given on how to request funding
by the responsible officer in charge of that area, otherwise a copy of the policy is
sent to the patient to review;
Patients will receive guidance via telephone discussions explaining the position of
the PCT; they will also receive letters outlining what is approved and funded and
method payments will be made. DH guidance is shared and, if required, a meeting
with patients would be available (this has taken place on one occasion). The PCTs
policy for overseas care is explained in the PCTs General Commissioning Policy,
available on the website;
The guidance has been offered by the public health doctor who is responsible for
funding out-of-area treatments both in the UK and overseas;
To date we have received only one request. This was dealt with by the ETR
Team and guidance was given verbally by telephone;
To my knowledge the PCT has invited and received members of the public to the
PCT for face to face meetings relating to guidance, appeals and complaints.
Various members of staff also offer assistance by telephone, email and PCT has a
website making some details available to patients;
We refer patients to look at the Department of Health website www.dh.gov.uk and
our website has information on how to make a complaint. We can also send a
leaflet on how to complain by post.







10 respondents provided us with copies of internal documents, and three told us that they
did have a leaflet which they gave to patients.
6.2.3
Local discussions or networks
Commissioners were asked whether they had discussed or met with other commissioners,
healthcare providers or patient groups around cross border health care. A summary of
responses is shown in table 6.2.
Section 6
54
Table 6.2
Discussions with commissioners and other organisations
Discussions or meetings with organisations
Other PCTs or commissioners
Strategic Health Authorities
NHS healthcare providers
Private healthcare providers
Intermediary organisations
Patient Groups
Other
Participated in no discussions
Don’t know
No (%) respondents participating in
discussions
5 (13%)
0 (0%)
2 (5%)
1 (3%)
0 (0%)
0 (0%)
2 (5%)
20 (53%)
8 (21%)
Commissioners were asked to describe the nature of any discussions held, and with whom.
Box 6.2 gives examples of responses.
Box 6.2
Examples of Local Discussions

As part of a session run by the PCT solicitors attended by PCTs and Trusts the
issue of cross border care was discussed;
Legal seminar;
Discussions around developing a Standardised Policy with [names of two] PCTs;
South East London PCTs (6 PCTS) have an Exceptional Treatments Group and
we have had discussions within this group, updating guidance, revising application
form, agreement to include this area within the individual funding request panels
for considerations and appeals.



Eight respondents told us that there were local or regional networks that discuss cross
border healthcare.
Examples of these networks include SHA based Specialised
Commissioning Groups; SHA Dental leads meetings; PCT collaborative; cancer and cardiac
networks; and sector based exceptional patients commissioning groups, comprising several
PCTs.
6.3
6.3.1
ANALYSIS OF DATA ON PATIENTS WHO HAVE RECEIVED TREATMENT
ABROAD IN MAINLAND EUROPE
Overview
This section of the survey focused on four areas:




Whether commissioners had assessed likely demand
The number of applications made for funding
Reasons why funding is authorised and not authorised
The number authorised, and details about these patients.
Section 6
55
6.3.2
Assessment of likely demand
Two organisations told us that they had undertaken work locally to assess likely levels of
demand for cross border health care in their organisation, 33 (87%) told us they had not, and
3 respondents did not know. Commissioners were also asked to provide any documents
describing this work. One PCT explained the process: “previous year’s activity is considered
and any trends or commissioning gaps would be factored into planning”.
6.3.3
Applications for funding
Commissioners were asked how many applications had been made for funding authorisation
under the various routes. 14 (37%) had received applications under E112, totalling 32
requests, 16 (50%) of which were from 3 (21%) of the organisations that had received
applications. 10 (26%) had received applications under article 56, totalling 18 requests.
Using form E112, the number of applications received by organisations is shown in table 6.3
and under article 56 is shown in table 6.4.
Table 6.3
Applications under E112 by organisation
Requests received by
organisation
1
2
3
4
8
Total
Table 6.4
Number of organisations
Total requests
7
3
1
2
1
14
7
6
3
8
8
32
Applications under article 56 by organisation
Requests received by
Number of organisations
Total requests
organisation
1
6
6
2
1
2
3
2
6*
4
1
4
Total
10
18
*NB 3 requests were retrospective claims, therefore handled under article 56
Additionally, 12 organisations had received applications with no route specified, of which one
had received 15, and one estimated between 5-10, thus totalling between 29-34
applications. Therefore across the 38 organisations, there have been around 79-84
applications, an average of just over 2 per organisation. One organisation also told us that
they received around one enquiry per month, but had not actually received a request. These
numbers appear to be low in comparison to the E112 totals alone derived from the DWP
Section 6
56
analysis. However, it does reinforce our view that very small numbers of requests are
currently being made for planned healthcare abroad.
6.3.4
Authorisations
Commissioners were asked the most common reasons why they authorise or refuse to
authorise patients for receipt of healthcare abroad. Box 6.3 summarises reasons for
authorisation, and box 6.4 summarises reasons for refusal of authorisation.
Box 6.3







Reasons for authorising receipt of healthcare abroad
Accessing maternity services
Where treatment is clinically justified, cost effective and would have been routinely
funded by the PCT but where treatment in the UK could not be provided without
undue delay
Continuity of care
Dental care
Expertise not available in UK, but would routinely commission in the UK, and/or
recommended by the local NHS specialist
Patient has been under care of a consultant abroad
Patient has ties to the country involved, e.g. the family is living there
Several respondents cited treatment, normally specialist, not being available in the UK as a
legitimate reason for funding healthcare.
Box 6.4






Reasons for refusal of authorisation for receipt of healthcare abroad
The treatment is available in the UK, and there is no clinical need for healthcare
abroad
Treatment would not be offered on the NHS, e.g. cosmetic surgery
The local waiting times indicate treatment available within 18 weeks
The treatment requested is dissimilar to the care pathway in the UK for a particular
condition
Prior approval had not been sought
No exceptional circumstances
Several respondents explicitly stated that they would not authorise treatment for a patient
who wanted to return to a European country, where they previously resided. One PCT gave
a detailed response, which is shown below:
“[name of] PCT do not routinely fund treatments outside of the UK because it is more difficult
to ensure clinical standards, patient safety and performance requirements in treatment
facilities outside the direct UK jurisdiction, it is more difficult to ensure patient care and follow
on care with treatment facilities where there is no established contractual relationship and
there may be other patient/carer travel costs that fall to the PCT which would be better
directed to fund direct patient care for the wider PCT patient groups”.
Section 6
57
Of concern must be those PCTs refusing treatment abroad if the care can be delivered
within local waiting times (even if those waits may be 18 weeks) but where clinical need may
indicate that the patient needs care more urgently, or where the treatment requested has a
dissimilar pathway. Additionally, four of the reasons given in box 6.4 gave us cause for
concern, as they run contrary to case law and domestic regulations and directions. These
findings indicate that commissioners, despite indicating earlier that they know and follow
guidance, in fact are not, and hence patients may be being disadvantaged.
6.3.5
Analysis of authorisations
There was a discrepancy in the data given to us by the PCTs. We were told that in total, 30
authorisations were issued, 20 under E112 and 10 under article 56, yet when the data on
each patient was analysed, only 6 were authorised under article 56, 23 under E112, and no
data was given for one patient. Table 6.5 compares the number seeking authorisation with
those receiving treatment.
Table 6.5
Analysis of authorisations
Treatment route
E112
Article 56
Route not specified
Total
Seeking authorisation
32
18
29-34
79 - 84
Received treatment
23
6
1
30
These figures indicate that only around 35% of requests for treatment abroad are authorised:
with a greater percentage under the E112 routes than under article 56. It is likely that many
of the requests for funding under article 56 are being made by individuals who have already
received treatment abroad, and are seeking retrospective funding, probably for healthcare
that the PCT had not authorised. This seems to be an area for differential interpretation, as
it appears that some PCTs do authorise treatment retrospectively, whilst others do not.
Section 3 of this report has provided a detailed analysis of the patients treated under E112,
using the data from the DWP. As indicated earlier in this report, the only route to information
on patients funded under article 56 is through data from PCTs. Below, we summarise the
findings on the patients funded through this route.
The country of residence of all six patients who received treatment under article 56 was the
UK. Two received treatment in France, whilst the others received their treatment in Malta,
Germany, the Czech Republic and Belgium. Four of the patients were being treated for
orthopaedic conditions: two received hip replacements (one for arthritis which according to
the PCT had not been previously authorised and one because they needed specialist care),
one (a child) was given a correction harness for hip dysplasia, and one required an
arthroscopic excision of the knee for glass in the knee. Of the remaining two patients, one
was being treated for grade 3 carcinoma of the breast (and was being treated abroad so
they could be near their family), and the second received bariatric surgery for obesity.
Section 6
58
Section 7:
Case studies of NHS
Commissioners
Key Findings

By the policies and procedures used in deciding on whether to fund requests for
treatment within the EU, the case study PCTs are potentially at risk of challenge by
patients on the decisions they reach.

All PCTs used funding panels to decide whether an individual should receive
funding for overseas treatment. These panels all consider undue wait based on
local waiting times rather than patient need, whether the pathway overseas is the
same locally and consultant support for treatment. In addition, some panels also
considered cost effectiveness, patient safety and governance. None of these
considerations are necessary for funding under Article 56 and so could potentially
be challenged as unlawful barriers.

The use of exceptional funding panels is resource intensive acting which in itself
acts as a barrier for PCTs being able to assess cases in anything but very low
numbers.

The case study PCTs reject patient requests for treatment within the EU unless
exceptional reasons for funding can be provided. They do not view treatment
overseas as a right that should be funded unless there are exceptional reasons to
withhold funding.

An opinion expressed in some PCTs was that patients should not have a right to
overseas treatment within the EU.. This cultural barrier could in part explain why
patients seeking treatment overseas are treated as exceptional funding cases.

Detailed knowledge of the different routes for planned overseas treatment amongst
commissioners was variable across sites. There is a suspicion that knowledge in
this area is even weaker amongst GPs and clinicians. As commissioners and GPs
are both stated in the NHS Choices website as first points of call for patients
considering planned treatment abroad, even a suggestion that their knowledge in
this area is not uniform is noteworthy.

Information was readily available for patients in four out of five PCTs on the policy
towards planned overseas care within the PCT. This was largely if not wholly built
upon guidance provided by the Department of Health Information to clinicians –
specifically GPs – on funding overseas treatment was not provided in two PCTs
although information on local processes has been provided in the other two case
study sites. .

Concern is not particularly with the information being provided, but rather the
processes that are used to make decisions.
Section 7
59
7.1
INTRODUCTION
To complement the commissioner survey, our research incorporated site visits to PCTs with
the aim of gaining an in depth understanding at a PCT level of:

The numbers of patients requesting overseas treatment
Advice and information given to patients and clinicians (including GPs) on overseas
treatment
The process by which a request for funding for planned overseas treatment is
considered including:
o
How the process is instigated
o
Who makes the decision and what factors are considered in making the
decision
o
How the decision for Article 56 or E112 is made
o
Whether there have been any challenges to decisions
o
Plans to deal with the future changes to entitlement to overseas healthcare



What the PCT sees as the barriers to allowing people to be treated abroad
Five PCTs volunteered to engage with this element of the research. They were all in the
South of England. This would ordinarily raise concerns over how representative findings are
for the country as a whole. However, the purpose of this phase was to provide depth to the
breadth of findings from the case studies. We also believed it is reasonable to assume that
given the consistency in findings relating to PCTs from other parts of the research, notably
the commissioner survey and ‘mystery shopper’ exercise, issues and findings from the case
studies would be relevant across the country. Ultimately the findings from this stage were
also consistent across sites indicating that they can be fairly generalised to PCTs across the
country accepting that there may be exceptions.
At each site we asked to speak to a senior commissioner who had responsibility for
overseas treatment or understood local processes, a PALS representative and a finance
officer. In two PCTs, all three of these roles were interviewed. In a further two, a finance
officer was unavailable and in one only a commissioner was interviewed.
We also interviewed a DHSSPS representative from Northern Ireland exploring similar
issues as the PCT case studies but also investigating cross border issues specifically related
to the Republic of Ireland.
We would like to thank all those who gave their time to engage with this element of the
research.
7.2
PATIENT NUMBERS
Confirming other parts of the research, PCTs reported being aware of very few cases of
patients seeking treatment overseas either through an E112 or Article 56. All areas were
Section 7
60
able to report in detail both cases that reached a commissioning level or were dealt with by
PALS.
Patient requests about overseas treatment that that reached commissioners ranged from
two over the past four years to twenty five in the past year. However, in the latter case only
four patients pursued treatment overseas as an option after an initial conversation, with the
majority of calls asking for information rather than about specific treatment.
Calls to PALS about overseas treatment were also low. In one area the PALS
representative stated that their service had not had a single call about overseas treatment in
four years. In the three other services spoken to numbers of calls were three to four per
year.
PCTs were unable to report how many times GPs had been asked by their patients about
overseas treatment, although in one PCT they were aware of at least one case that had
started with a request to a GP and in another they suspected that GPs may be ‘filtering
patients’ away from overseas treatment. There was no evidence to back up this statement.
There was only one reported request across all the PCTs for reimbursement for dental
treatment. No PCT had seen an increase in patients requesting or enquiring about funding
for overseas treatment over the past three or four years.
7.3
INFORMATION, KNOWLEDGE AND ADVICE
Written information for patients on planned overseas treatment was available in four of the
five PCTs visited and was broadly comparable across these sites. The information available
to different extents sets out the criteria for funding overseas treatment, the actions the
patient must undertake to be considered for funding and the process by which a decision will
be made. In two PCTs this information is made available on the PCT website and in all four
PCTs is available when a patient enquires about planned treatment abroad. One PCT
questioned whether they were ‘advertising patients’ option to go abroad well enough’.
The information available was built on information taken from Department of Health websites
and guidance and so therefore is accurate in terms of its description of different funding
routes. In one PCT the information provided was taken directly from the NHS Choices
website, which was generally well thought of across PCTs – particularly by PALS. However,
searching for ‘overseas treatment’ on the NHS Choices website brings up some curious
information that does not reflect any practice that we found in our research or indeed have
been aware of happening for a number of years28. Searching for ‘planned treatment abroad’
does provide clearer information however.
Looking beyond written information, most people spoken to had a basic understanding of the
difference between Article 56 and E112 routes for funding, but there were two
commissioners who were not clear of the differences and one commissioner who believed
28
See http://www.nhs.uk/chq/pages/907.aspx?categoryid=70&subcategoryid=172
Section 7
61
the E112 was a form that a patient had to complete. In addition, as will be discussed further
below PCTs seemed to be very concerned with governance issues around Article 56. This
suggests they do not fully understand the fact that patients funded under Article 56 are out of
the jurisdiction of the NHS and transitively do not have a thorough understanding of the
Article 56 processes.
Two PCTs stated they that provided information on overseas treatment directly to clinicians,
including GPs. Whilst no PCT could provide anything other than anecdotal evidence of rare
requests for overseas treatment from GPs that PCTs deemed inappropriate, there was a
suspicion that GPs were ‘filtering’ patients and providing advice that may not be accurate.
With this in mind, there was a request from three PCTs that better information needs to be
made available from the Department of Health for patients but specifically for GPs and
clinicians on overseas treatment. Again, this seems prescient given that GPs are identified
in the NHS Choices information as being a local commissioner in England to approach about
planned treatment abroad.
7.4
PROCESSES FOR CONSIDERING PLANNED TREATMENT ABROAD
Requests for funding for planned treatment abroad are seen by all five PCTs as requests for
exceptional funding rather than routine exercise of choice. All the PCTs use mechanisms
and processes to make the decision whether or not to fund that are used for other individual
patient funding requests. In all patient cases talked through at each site that had reached
the point of a decision being required a funding panel had made that decision.
In two of the PCTs it was stated that only the ‘questionable’ cases would end up at panel,
but in practice all requests up to the time of the interview had been ‘questionable’ and
therefore decided by a panel.
A pre-requisite for prior authorisation for consideration for funding in three PCTs was that a
clinician – either a GP or consultant - must instigate the process although a patient may
make the initial request. In the other two PCTs, whilst a patient can initiate the process,
clinician input is still required for funding to be considered.
Example
A patient was seeking treatment for carpel tunnel syndrome in both hands. The PCT would
ordinarily fund treatment for one hand at a time, but the patient had found a consultant in the
EU who would treat both hands at the same time and sooner than the treatment could be
provided locally. The patient was told that as this was not the ordinary patient pathway in
the PCT there would need to be 'undue delay' and that their consultant would need to
approve treatment.
Of concern is that the approach adopted by the PCT, of this proposed treatment regime ‘not
being the ordinary patient pathway’ is completely irrelevant in terms of patients exercising
their rights to cross-border treatment.
Section 7
62
In one PCT an application form is sent out to clinicians or patients when a request for
funding for overseas treatment comes in. The application form collates information on
patient demographics and condition, the treatment history and treatment being sought and
the clinical evidence of effectiveness of the treatment. Asking for information on clinical
effectiveness seems somewhat unusual given that experimental treatment or treatments not
routinely funded by the PCT would ordinarily be considered for planned treatment abroad.
There are insufficient cases to evaluate whether the application form simplifies the process
or from a patient perspective actually acts as a barrier to following through a request for
funding.
The factors considered by a panel in deciding on funding across all sites were:




Does consultant support this?
Is there an undue wait?
Is the patient resident?
Is this part of a pathway they would ordinarily fund?
In addition, individual panels also considered several other factors in making their decision
including:



Is the treatment cost effective?
Are there any concerns about patient safety?
Are there any governance issues?
In terms of NHS practice and preparedness, the above give grave cause for concern as they
can be construed as being barriers to patients exercising their rights to obtain treatment
abroad. It appears that the NHS does not appreciate the risks they are running in taking
such an approach.
Example
An active blind patient needed a hip replacement.
The patient wanted intensive
physiotherapy in hospital before returning home and also requested a single room post
operation as their blindness impinged on their ability to navigate a ward where objects may
be continually moved. The local hospital refused to provide this level of care but the patient
found an EU hospital that would and so approached the PCT to see whether he could go for
treatment in the EU hospital funded under Article 56.
A local commissioner visited the patient and informed him that they would approach the local
acute trust and see if they could meet his needs. The hospital refused the PCT as they had
the patient. The commissioner took the case to an exceptional funding panel who agreed to
fund the patient under Article 56. Whether the case involved 'undue delay' was not
considered.
Section 7
63
In one PCT £30,000 per annum was set aside for individual funding requests for ‘non-NHS,
non-contracted services’. Funding for patients receiving planned treatment abroad came out
of this amount.
Of the small number of cases talked through across sites, few appeared to be cases of
‘undue delay’ which indicates that this is not always a significant determining factor. When
‘undue delay’ was considered, it appeared to be focused on current waiting times within the
PCT rather than an individual patient’s needs.
Both these findings resonate with the
findings from the review of E112s at the DWP. Whether patients went down Article 56 or
applied for an E112 was always in the hands of patients. No PCT routinely advised a patient
as to which route they should go down or used formal criteria to decide this on behalf of a
patient.
In terms of documenting the process, all PCTs understood that there needed to be
transparency in how the decision was reached with two PCTs stating that they believed they
could be challenged on process but not decision. One of these PCTs kept very detailed
records on each case going to the funding panel and what the panel had considered in
reaching its decision.
In all PCTs, travel and accommodation costs would not be routinely reimbursed unless these
costs would have been covered for treatment locally. The vignettes of cases shown in this
section provide a flavour of the types of cases being considered by PCTs and the thought
process going into that consideration. They highlight the time involved in dealing with these
cases, which by three commissioners was described as ‘substantial’. They also highlight the
inconsistency in how patient pathways and ‘undue delay’ are interpreted in different areas.
Two PCTs reported challenges to a decision not to fund, one of which was turned down on
appeal and the second resulted in the PCT Chief Executive agreeing to reimburse treatment
even though the patient did not meet the criteria for funding. Only two PCTs said that they
were beginning to think how to deal with potential changes and increases in demand for
treatment abroad. One of these PCTs said they were specifically going to look at dentistry.
Planning in both PCTs was at an early stage.
7.5
7.5.1
BARRIERS TO FUNDING PATIENTS ABROAD
Overview
Barriers for PCTs to fund patients abroad, all of which are contrary to the law, fell into the
following categories:




Financial constraints
Governance
Comparable pathways
PCT culture
Section 7
64
7.5.2
Financial constraints
Two PCTs questioned where the money would come from to fund treatment abroad if more
people decided to exercise this choice. This is curious given the PCT only has to fund what
they would ordinarily fund up to the cost they would ordinarily pay so there should be no
impact on the cost of direct patient care.
One PCT stated that translation costs if bills for treatment are sent to the PCT without prior
authorisation could be substantial, especially given that the translation will be of language
that is medical and technical. The biggest financial constraint that could be seen was the
resource constraint of the current processes involved to fund overseas treatment. Given the
time that can be taken for a single case as they are all treated effectively as exceptions, the
process to make a decision requires a level of resource that means if numbers of people
seeking treatment abroad increased it is difficult to see how funding panels would cope.
7.5.3
Governance
Whilst one PCT assumed that a state hospital in the EU offered the same standard of care
as in the UK, all PCTs stated that assuring that the quality of care a patient received in an
overseas hospital – especially if they use Article 56 in a private hospital – was a barrier to
allowing people to have treatment overseas. Two PCTs stated that they would try to
investigate the quality of care offered by looking at websites. The recommendation of a
particularly hospital or consultant by a local clinician was considered to be an important way
of ensuring the quality of care by all PCTs.
This represents a major risk, as people using the Article. 56 route are effectively stepping
outside of NHS jurisdiction, however these actions could be construed as confirming a
continuing duty of care.
On top of the concerns for patient safety, governance was seen as a barrier for two further
reasons. If something goes wrong because of poor quality of care the PCT could be left to
fund treatment not only to treat the original condition (again) but also to treat complications
arising. In addition, PCTs were not clear where liability would lie should someone seek
compensation because of inadequate quality of care.
Finally, if patients seek reimbursement for overseas treatment without prior authorisation,
commissioners felt that without a clear way of assessing quality of care they could be
funding treatment at a level of quality that they would not accept locally.
These concerns and actions are understandable. However, patients travelling under Article
56 should be informed that they are stepping outside of NHS jurisdiction. If PCTs are
concerned about quality of treatment overseas and look at this in making a funding decision,
this could be inferred that they actually do have a legal duty of care that in this case they do
not.
Section 7
65
7.5.4
Patient Pathways
A key consideration of the decision made to fund care is whether the patient pathway
followed in the planned overseas treatment is the same as that locally. PCTs are effectively
using a comparison of pathways to analyse whether this is treatment that would be available
locally. This becomes particularly problematic if people seek reimbursement for treatment
retrospectively as PCTs try to understand exactly what has been done with sometimes
incomplete information. This is understandable, but irrelevant to the consideration as to
whether to reimburse.
7.5.5
Culture
In three PCTs there was a belief by commissioners –vociferously expressed in some cases
– that allowing patients to have treatment abroad was not something they agreed with.
Coupled with the fact that funding for overseas treatment is dealt with as an exceptional
request, low numbers of people currently requesting treatment and the lack of uniform
knowledge about overseas treatment, these beliefs could result in a culture of reluctance to
fund treatment abroad even where there is a case that should be funded.
As one PCT stated “overseas treatment is not something we would routinely fund”
7.5.6
Summary
Looking at these barriers together suggests that PCTs are actually placing obstacles in the
way of funding treatment that should not only be there but also open the decisions of the
PCT up to challenge by patients.



Given funding can be no higher than that the PCT would pay anyway, financial
concerns should be irrelevant. A resource intensive decision making process is not a
legal barrier for funding.
Governance issues under Article 56 should not be the concern of the PCT as the
patient is outwith the jurisdiction of the NHS.
A PCTs’ belief and position on what an individual’s right to overseas treatment should
be is irrelevant to the rights existing under legislation and case law.
The one area which is ambiguous is the effort put in to match patient pathways, and the
Department of Health should consider issuing more robust guidance on how a
commissioning body should decide how to interpret whether a treatment would be ordinarily
funded locally. All of the above indicate the putting in place of unjustified barriers to patient
mobility and thus represent significant risks to the NHS.
Section 7
66
7.6
NORTHERN IRELAND
Although there is now only one Board covering the whole of Northern Ireland, this is a
relatively recent event and the person we spoke to could only relate experience from one of
the previous smaller Boards. However, they felt that their experience would reflect other
Boards and they also were able to talk about the current position.
In their former Board, there were no successful Article 56s as far as they are aware. There
had been a couple of applications that were refused but had been considered good test
cases for the position in Northern Ireland.
One of these cases was for organ transplant and explains their processes well.
Example
A consultant had approached the Board about a patient wanted reimbursement for treatment
already received in Germany as part of initial treatment for kidney transplant. The patients'
brother lived in Germany and was willing to donate a kidney but wanted the operation in
Germany rather than the UK. The Health Board sees such a request as a legal issue and so
sought legal advice from the Board's legal department. The issues they were concerned
about were undue delay - from a patient rather than strict waiting time perspective and
whether there were any contraindications. The individual in the Board considering the case
and the Board legal department felt that as there was no undue delay - the patient could
have been seen in the same time period in Northern Ireland - the costs were not reimbursed.
Interestingly this was all lead by an individual in the Board rather than going to a panel.
In terms of formal protocols and processes when the first set of guidance around funding
treatment in the EU came out the Board looked at what process they would use for extra
contractual cases and what extra steps would be needed with Article 56s. It was decided
that they would check with the consultant for undue delay and whether they would ordinarily
fund this pathway.
The person we spoke to could not see a situation where they would ever fund an article 56 pathways would never be identical and there are no real problems with waiting times.
Looking at cross border relationships with Southern Ireland, there are quite a number of
elective access services where they have contracts with Southern Ireland but these are just
treated as contracted services within Northern Ireland. Only a small number of cases are
requested for non contracted services by consultants and these always go as E112s if they
have time to apply as they are aware that the Board does not have to fund them.
There had been a situation in the past where consultants were sending patients to Dublin for
bone marrow transplantation without E112s or prior notification of the Board. A bill then
Section 7
67
came in for almost £1million. The hospital in question has now requested E112s before
allowing treatment.
One problem identified with issuing E112s for Southern Ireland was that it is difficult to
identify which services are privately or which publicly funded
Section 7
68
Section 8:
Mystery Shopping
Commissioners
with
NHS
Key findings
 The findings from the mystery shopper reinforce and build on those from the
commissioners’ survey and case studies;
 The initial process of obtaining the contact details for each organisation was mostly a
relatively easy process as they had organisational websites containing the relevant
information;
 Once the organisations were contacted all but one of the operators spoken to were
found to be very polite, helpful and honest about not knowing who to pass the caller
on to in relation to the query of planned health care abroad;
 There were differences identified in whom to signpost onto depending on the location
of the organisation. Scottish Health Boards were found to be more articulate in the
process as they do regularly have patients accessing healthcare in England as do
those in Northern Ireland;
 English PCTs were found to vary and disparities were identified with the information
given and most did not immediately know the appropriate department to deal with
this type of request. PALS or the customer relations teams were found to be the
most popular choice to which to refer the mystery shopper;
 The information given was often basic and usually included a signposting back to the
callers GP. Where more in depth information about the process and how to apply for
funding was obtained, it was usually from the PCTs who had dealt previously with
similar requests;
 None of the PCTS and only one of the Scottish Boards appeared to have leaflets to
explain to members of the public how they can access health care abroad;
 Only one of the PCTs said that they received regular queries about accessing
planned health care abroad. The majority of PCTs said that they had only ever
received one or two enquiries about health care abroad and one said that they had
never had an enquiry;
 Although organisations appear to have few requests for this type of information at
present, the difficulties experienced in obtaining the correct information highlighted a
need for the organisations to improve both the knowledge within the organisations
and the information given to members of the public. These difficulties represent
additional barriers to patients seeking healthcare abroad.

Taken as a whole, one conclusion that can be taken from the mystery shopping
experience is that patients are likely to be passed from pillar to post, and in the
majority of cases there is no-one at the PCT who is a clearly identified repository of
information and expertise. As stated earlier, these represent risks and barriers.
Section 8
69
8.1
INTRODUCTION
The purpose of the mystery shopping activities was two- fold:
 To investigate the experiences of potential patients who wish to find out about the
possibilities of receiving healthcare abroad
 To chase up non-respondents to the NHS commissioner survey
One member of the study team, who had a clinical background, but who also had experience
working in public patient forums and with the development and delivery of information
services to cancer patient, took on the role of mystery shopper. We did not attempt to test
the accuracy of advice given under a range of scenarios.
8.2
METHODOLOGY
We used our management database of NHS commissioners, which was drawn up and was
continually updated during the undertaking of the NHS Commissioner Survey, by identifying
all PCTs and health boards from which we had no response to the survey, who told us that
they could not complete the survey for a variety of reasons, or who gave us alternative
contact details but from whom we still had not received a survey.
We selected a sample reflecting geographical diversity and responses. Our mystery shopper
attempted to contact 32 commissioners over three days, successfully speaking to people in
21 PCTs, and three Health Boards in Wales and Scotland. We also interviewed, though not
through the mystery shopping route, two individuals in Northern Ireland, whose names were
provided to us.
The starting point for contacting the commissioner was always their website, rather than our
contact details: the intention being to replicate the pathway of a member of the public. Our
mystery shopper called that number and asked to speak to someone who could tell them
how to find out about receiving planned healthcare abroad. Our mystery shopper worked to
a protocol and a script, both to ensure comparability across interviews, and also to ensure
she did not mislead those we spoke to. When the appropriate person was contacted, our
mystery shopper told them who she was, and the purpose of the call.
Our mystery shopper recorded, for each commissioner:
 How quickly the phone was answered at the first call and the response of the person
answering
 To whom she was directed, and the steps taken including whether she had to call
back, or they called her, before reaching the appropriate person
 What the response of the commissioner would be to someone investigating treatment
abroad.
She also updated our contact details so that we could send on to them a survey, if not
completed.
Section 8
70
8.3
8.3.1
FINDINGS
Initial phone call
Twenty four organisations were contacted by a mystery shopper over a period of three days,
with a lapse time of two weeks. The length of the calls were recorded from the initial dialling
of the PCT or Health Board telephone number, as found on the PCT/Health Board website,
to the time it took for someone from the organisation to answer. Only one PCT out of the
twenty four organisations did not answer the call and one PCT was found to be frequently
engaged but did answer after four attempts. Ten of the PCTs and three of the Health
Boards answered the call within one minute and nine PCTs answered within two minutes.
Two of the PCTs used an automated service which placed the caller in a queuing system
before actually speaking to someone, this increased the time of these calls by an additional
minute.
The call was normally initially answered by a telephone operator/receptionist except on one
occasion when we contacted an organisation in Northern Ireland, where one of the
managers answered the call first. On three separate occasions the mystery shopper was put
on hold whilst the operator/receptionist sought advice as to whom the mystery shopper
should speak to. Four PCTs transferred the mystery shopper to answer machines without
an explanation or name of the person to whom they were to speak. Two receptionists
informed the mystery shopper that she first needed to contact her GP, and another told her
to ring NHS Direct. A third receptionist herself gave advice then put the mystery shopper on
hold for an additional six minutes while she spoke to a colleague in contracting, following
which she confirmed the information given. The mystery shopper was cut off on three
occasions and three operators/receptionists redirected her after having initially directing her
to incorrect numbers. On five occasions the mystery shopper was directed to PALS, on three
occasions to customer services, twice to a member of the commissioning team and once to
an operations manager. On eight occasions the mystery shopper was given an alternative
number to ring.
One of the Scottish Health Boards contacted passed the mystery shopper on to three
separate areas within their organisation and then finally asked her to ring the Director of
Finance the following Monday. Another Scottish Health Board suggested the mystery
shopper contact the Scottish Government for further guidance in relation to healthcare
abroad for Scotland.
One English PCT gave her contact details of a second person, who then passed her on to a
third person, who again passed her on to a fourth and finally to a fifth person. After speaking
to the fifth person, the mystery shopper was contacted four days later by a member of a
PALS team in another area that apparently covered this particular PCT.
In the opinion of the mystery shopper, most of the organisations contacted were friendly,
open and honest about not knowing to whom they should initially direct the mystery shopper
to. All the Trusts were very apologetic about not returning the surveys once the mystery
shopper had introduced herself to the appropriate person.
Section 8
71
Out of the sample of twenty four organisations, four PCTs were seen as reasonably helpful
in that they were able to discuss the process around accessing healthcare abroad, giving
advice on the process for applications and the eligibility criteria, although we have concerns
about these eligibility criteria, as they may (as discussed in earlier sections) be unjustifiable
barriers to patient mobility. Five other organisations were also helpful and returned the call
either on the same day or a couple of days later to describe how to access health care
abroad.
Ten of the organisations contacted did not appear to feel confident in discussing the issue of
planned healthcare abroad. Of those who did have some knowledge, two organisations told
the mystery shopper that they did not like taking calls about treatment abroad because as
one stated “it is so complicated”.
8.3.2
Next step (s)
The time it took for the mystery shopper to be passed from the operator or receptionist to the
next person varied from organisation to organisation, ranging from two minutes to six
minutes depending, it appears, on how confident the operator was about to whom the
mystery shopper should be directed. The mystery shopper spoke to a total of eight
operators/receptionists who passed her onto their PALS teams or customer service staff.
On two occasions the mystery shopper was directed to operations managers and another
two PCTs signposted her to the commissioning team.
Box 8.1
Response via NHS Direct
The mystery shopper was referred by the operator/receptionist to the walk in centre
who then told her to ring NHS Direct. On calling NHS Direct the mystery shopper
declared her identity and purpose, as the assessment process required the provision
of symptoms and problems. Details were taken and NHS Direct informed her that
she would be called back the next day
NHS Direct did call back the next day with very helpful information about accessing
the NHS Choices website, the Department of Health’s website and also a telephone
number for the Department of Health overseas policy unit. They explained how they
would always sign post callers requesting information about travel abroad to the most
appropriate websites.
On twelve occasions the mystery shopper left answer machine messages asking for the
relevant people to call her back, giving her name, a mobile telephone number and a brief
message about seeking advice on planned healthcare abroad. The time it took for people to
call back was recorded. Two PCTs responded immediately and returned the call within the
same day, another returned the call the following day as did NHS Direct (see vignette above)
and three others phoned back within a week. On completion of the research, five
organisations had not returned these calls.
Section 8
72
The number of steps or people involved in the process from the initial call to the next step
varied. Two organisations took just one step of transferring to the right person. Eleven
organisations took two steps by referring on to one person who then transferred on to
another. Six organisations took three steps, one took four, one took five, one took six and
another took seven steps to allow the mystery shopper to speak to the most appropriate
person.
Another PCT asked which specific country the treatment was in and described how to use
the E111, (NB the term E111 was used, not the correct term EHIC), in countries which were
part of the European Union. This is noteworthy given the mystery shopper was requesting
information on planned healthcare abroad. One PCT told the mystery shopper that their
customer service person was on holiday but would call her back and did so a week later.
One of the Health Boards, after being asked the questions according to our topic guide,
asked the mystery shopper if she was a reporter. After an explanation that she was a
mystery shopper and on describing the purpose of the study, the person from the Health
Board became more co-operative and explained that she had only ever had one enquiry
about travel abroad in all the time she had been in post.
8.3.3
Response when appropriate person reached
Once the mystery shopper had reached the most appropriate person, what she was told
would happen if wanting to seek healthcare abroad varied. Two typical explanations were
given in boxes 8.2.and 8.3.
Box 8.2
Typical Response: PCT A
The commissioner explained that If treatment was available within the UK within a
timeline of 18 weeks then there would not be a case to go abroad if it was expected
that the NHS would pay. However if the timeline was longer than 18 weeks then it
would be possible to apply for funding but first must seek approval from the PCT and
the GP to support an application and emphasised that they do not have any quality
checks for healthcare abroad. If you were seeking treatment abroad privately then it
would be up you to find out any information on the treatment or facility abroad and
the NHS wouldn’t help with this.
Box 8.6
Typical Response: PCT B
An operations manager from this PCT described how to apply for funding from the
PCT but explained that the PCT would not fund travel or expenses such as
accommodation. The PCT operations manager stated that you would need a
clinicians support first and it would also, depending on the type of treatment you were
wanting, depend if the NHS would fund it. For example if the NHS doesn’t normally
fund a procedure here in the UK then they would not fund this abroad either.
Although this PCT did not use any particular leaflet to aid the public with health care
abroad, they did adhere to a policy called the Effective Use of Resources which
would soon be available to see on line.
Section 8
73
Another PCT explained the need to liaise with the GP first as they would need to apply for
funding from the PCT as long as the service needed was not provided anywhere else in the
UK and was not plastic surgery. Several PCTs referred patients to their PALs staff, but two
PALS staff to whom the mystery shopper was referred, did not appear to have full
knowledge and information. As one stated: they had never had any queries about treatment
abroad.
One Scottish Health Board planning officer asked the mystery shopper “would you want to
go abroad?” and then proceeded to describe the need to first see the GP or consultant as
they would need to apply to the Health Board for any treatment abroad. Only one of the
Scottish Health Boards stated that they had a leaflet to direct a patient on how to access
healthcare abroad.
One of the English PCTs said that they used a policy. Finally, out of the PCTs contacted
only three and NHS Direct directed the mystery shopper to the Department of Health
website.
One PCT stated they received two to three queries a month about treatment abroad and that
they found the Department of Health’s overseas person to be very useful and helped them
with any queries regarding eligibility. Another PCT stated that there were specific guidelines
to help with the process.
As previously described, once the appropriate persons in PCTs and other commissioning
organisations were aware of the purpose of the mystery shopper’s query and once she had
identified herself, all of those spoken to were found to be extremely accommodating and
very helpful. A small number of people to whom the mystery shopper spoke initially were
found to be unhelpful in their initial signposting, often referring the mystery shopper back to
the GP or directing the caller to seek healthcare here in the UK instead. A number of PCTs
did have to take certain information from the caller in order to ask someone else and then
call the mystery shopper back with the updated information. Four of the PCTs who said they
would call back had yet to do so at the time of writing the report, and we were also waiting
for a response from the contact in Northern Ireland.
Taken as a whole, one conclusion that can be taken from the mystery shopping experience
is that patients are likely to be passed around a number of staff and departments, and in the
majority of cases there is no-one at the PCT who is a clearly identified repository of
information and expertise. As stated earlier, these represent risks and barriers.
Section 8
74
Section 9:
Survey of Professional
Organisations and Patient
Associations
Key findings
 These organisations appear to have a role to play in advising patients about seeking
treatment abroad;
 Most focused their role on problems associated with seeking private care abroad,
especially choice of facility, and what are the roles and responsibilities of the NHS
when patients have complications on returning to the UK;
 The DH probably should consider offering guidance to these organisations as to the
rights of the patients and the obligations of the NHS.
9.1
INTRODUCTION
A survey was sent to 30 professional organisations and patient associations (this survey is
available in the technical report). The purpose of the survey was to investigate the role
played by these organisations in advising the public about the receipt of healthcare abroad.
The organisations selected for participation in the survey were those associated with
conditions for which our research indicated treatment was likely to be obtained abroad.
Conditions targeted were:

Cardiac;

Orthopaedic

Arthritis

Dental

Infertility

Plastic surgery
We also included in our survey generic organisations such as Age Concern, and Patients
Associations.
We obtained postal and email addresses from the organisations’ websites. For those
organisations without an email address, we sent hard copy surveys to their postal address.
We sent two email or postal reminders, followed up by a phone call to the organisation. One
completed the survey over the phone, and several gave us alternative contact details. A
further two organisations told us that this survey was not appropriate for them as they were
purely for educational and training purposes. Of the 30 organisations contacted, we
received completed surveys from 13 organisations (43% response).
Section 9
75
9.2
9.2.1
ANALYSIS OF RESPONSES
Overview
The survey focused on four areas:




9.2.2
Knowledge of the parallel systems for patients seeking planned healthcare abroad;
Receipt of requests for guidance, advice or information from members of the public
about receipt of healthcare funded by the NHS or privately organised and funded;
Participation in discussions with healthcare commissioners or providers;
The role of their organisation in offering advice on the receipt of healthcare abroad.
Analysis of responses
Knowledge of systems and processes
Six organisations (46%) were aware of systems for the authorisation of healthcare under
1408/71 (E112), and the same six were aware of systems for authorisation under article
56.Three (23%) organisations were aware of the proposed new directive from the EU on
cross border health care. One of the respondents told us “[I was a] key stakeholder so have
been invited to give views/attend events on the issue”.
Requests for information
Only one organisation has received any requests for guidance, advice or information from
members of the general public about receipt of healthcare abroad funded by the NHS. The
organisation told us “[we] responded positively”. However, six organisations (46%) told us
that they had received requests for guidance, advice or information about receipt of
healthcare which would be privately organised and delivered.
Comments from respondents, in response to this question, include:
“[Name of organisation] does receive enquiries about private cosmetic surgery abroad. We
have published a patient information sheet which can be accessed by the public from [our]
website. It summarises the answers to questions posed by members of the public and
cautions which they need to bear in mind if they travel abroad for private cosmetic surgery”.
“Breast augmentation is often cheaper abroad. My organisation will sometimes be asked
advice by a member of the public prior to going abroad, at which point my organisation will
advise not to undergo surgery abroad. More often than not, [we] hear from members of the
public after they have undergone surgery abroad when they are seeking aftercare advice or
assistance when things go wrong”
“Patients often request info on choosing private healthcare abroad”
Section 9
76
“Requests for information include: why is dental treatment so much cheaper abroad? Or
looking for a recommendation, which we are unable to provide”.
Participation in discussions
None of the organisations had participated in discussions with health care commissioners or
providers around the issue of health care abroad, including PCTs, SHAs, NHS healthcare
providers, private healthcare providers and intermediary organisations. One organisation
had sought guidance from the DH in respect of patients who had experienced problems
following cosmetic surgery abroad, for example the roles and responsibilities of the NHS
once these patients return to the UK.
Role of organisations
Ten organisations (77%) believed that offering advice around seeking healthcare abroad is
part of their role as a patient association or professional body. One explicitly commented
that this would be part of their member support remit, and other that concentration on this
would be outside their remit.
Eleven organisations offered further comments on their role, including:
“Here to provide support and advice. As part of their choice is to go abroad, then we feel we
should give as much info to make this informed choice”;
“If asked about this we would do our best to find out what the regulations were”;
“Only for the transfer of existing patient ongoing treatment NOT as seeking an alternative
access to new treatment”;
“Patients must be aware of the risks and areas for consideration of entering into healthcare
arrangement overseas”;
“The [organisation] aims to provide as much advice as possible for any woman with or
considering breast implants. It is my opinion that opting for surgery abroad for the sake of
saving money is not ideal”;
“We aim to provide answers to whatever questions patients ask”;
“We can discuss pro's and con's of receiving treatment abroad and any other dental issue
that may arise from this. We already do this with private dental treatment abroad”;
“We do not offer advice on medical issues we would, in the case of medical conditions
signpost to specialist support organisations or professional bodies, and individuals GP”;
Section 9
77
“We provide information for patients so they are better able to be aware of the potential
pitfalls if something adverse occurs, once they have returned to the UK and do not therefore
have access to the surgeon that performed their private cosmetic operation”.
Section 9
78
Section 10:
Conclusions and
Recommendations
Key Findings






Current demand for planned overseas healthcare funded by the NHS is very low.
Whilst a 60%of the British public do not appear to have any intrinsic barrier to
receiving treatment abroad, revealed preference from patient behaviour suggests
that the desire to be treated close to home in a system that is understood outweighs
any perceived benefit from treatment overseas.
This lack of demand could be due to a lack of knowledge of rights EU citizens have
to treatment abroad, especially to routine treatment where people may be more
willing and indeed already be receiving treatment in the EU. The new Directive may
raise the awareness in the population of their rights and so potentially raise demand.
An increase in demand could also arise if waiting times for treatment increase in the
future as people indicate this as the main issue that would drive them to seek
treatment abroad.
Processes adopted within PCTs to assess cases focus on the use of exceptions
panels. These processes are the same as those for any patient seeking funding for
treatment not ordinarily provided by the PCT. These processes are resource
intensive and time consuming and as they are exceptions panels some of the factors
considered in making decisions should not be considered for requests for funding for
treatment in the EU.
Even with only a small increase in demand, especially for routine treatment, the
current resource intensive processes adopted to assess requests for funding, would
struggle to cope.
Commissioning in this area is clearly found complex and challenging locally.
Processes are resource intensive. Whether through inadequate guidance or poor
interpretation of guidance, commissioners are applying criteria in the decision making
process that have no basis in legislation or case law. The potential consequences of
making a wrong decision are significant. Current low demand for overseas
healthcare makes this a lower priority area locally than it is nationally. In our opinion,
these facts points to this being an area that should be considered for national rather
than local commissioning.
Looking at the evidence in its totality, it provides clear and consistent messages
about the demand for overseas healthcare and processes in place locally and
nationally when NHS funding for overseas treatment is requested.
Section 10
79
10.1
DEMAND
The research provided evidence that current demand for overseas healthcare for treatment
that could be funded under the NHS is insignificant when compared to NHS funded
treatment within the UK. Patients requesting and/or receiving funding through E112 or
Article 56 are very small across PCTs and Health Boards – especially if patients travelling for
maternity care are excluded. In some areas, local commissioners have not in the recent
past funded any treatment within the EU or received any requests for funding.
The public survey confirmed this finding of low current demand, providing further evidence
that a tiny proportion of the population have sought NHS funding for pre-planned healthcare
in the EU. Around 5% of the sample said that they had considered going abroad for
healthcare however and over 60% stated that they would consider going abroad, with the
majority of these people stating that they would go abroad if waiting times were too long.
These findings are reinforced by the findings from the focus groups, where waiting times
were a driver to seek healthcare abroad.
Whilst we cannot provide strong evidence on the scale of any future demand for planned
treatment in the EU, the evidence found does suggest that there is a willingness to consider
going abroad in a majority of the population – although a majority of the population would
also not know where to go for information if they were considering overseas treatment.
Further, the mystery shopping indicated that PCTs do not necessarily have the processes or
knowledge to deal with queries, and may not be offering helpful or accurate advice. Taken
as a whole, the lack of information could be a barrier to patient mobility.
It is conceivable that this latent demand will surface into actual demand when the new
Directive comes into force and people are, in theory, more easily able to exercise their rights.
Given the low level of demand currently it is in the opinion of the researchers more likely that
the findings of the focus groups and public survey actually show that there is not a
significant cultural barrier for a majority of people to receiving treatment abroad. If the time
should come for these same people to need an operation or treatment for a serious
condition, patients already show by revealed preference that they would like that treatment in
a system they understand and close to home and family – just as those foreign nationals
seeking E112s for treatment in their own countries. Only when a specific treatment is
unavailable or a perceived better pathway or quality of treatment is on offer in the EU do
British nationals seem to seek or be recommended for treatment overseas.
Restating this point slightly differently, the lack of translation of potential into current demand
for overseas treatment could be that supply of healthcare in the UK meets current demand
and so people do not need to go overseas. Given the change in emphasis away from
targets around waiting times, it may be that if this results in waiting times increasing or a
significant return to waiting lists then in effect supply will no long meet demand and more
patients may seek treatment abroad. This is especially pertinent given the primary reason
people in focus groups and the survey gave for seeking healthcare abroad was waiting
times.
Section 10
80
Despite this, the new Directive may still increase the demand for overseas treatment
amongst people with no intrinsic barrier to treatment outside the UK, perhaps even for
routine treatment such as dentistry although we found no evidence of this.
The reality is however that current demand for treatment may also be being suppressed by
current processes to assess requests by local commissioners. Processes that themselves
would appear to be completely unsuitable for even small increases in demand.
10.2
PROCESSES
Local health commissioners could fall along a continuum of access to overseas healthcare,
from a policy of not allowing overseas treatment to a fully supportive policy with processes
that assess each case fairly within existing legislation. Evidence from the research would
strongly suggest that there are many – probably a majority – of local commissioners who are
at the wrong end of that continuum, and possibly no local commissioner completely at the
right end. If anything, the national picture is likely to be worse than that found through our
evidence gathering as it is likely that those that did not engage with the research failed to do
so either because this is a very low priority area, there is no one locally who is responsible to
assess requests or both.
One local commissioner refusing funding without consideration of the case is one too many,
but our evidence points to several taking this stance with, in our opinion, a high likelihood of
other commissioners also adopting this position. Many local commissioners that would in
theory assess a request have implicit barriers to patients receiving funding in the form of
poor communication and provision of information and advice that is inaccurate. This is
strongly evidenced by the mystery shopper exercise.
In our opinion, the evidence suggests that the high proportion of local commissioners at the
wrong end of the continuum is due to the low number of cases and also, at least in some
areas, to an underlying implicit belief that patients should not be allowed to go overseas for
treatment with NHS funding.
The case studies in particular showed that there are some local commissioners who are
positive about funding overseas treatment and have tried to make information available and
put in processes to fairly assess cases. However, all evidence points to a coherent picture
of requests for overseas treatment being assessed as requests for exceptional funding with
the resultant processes that this entails. This process treats patients requesting overseas
treatment as making an exceptional request that would not ordinarily be funded which is the
antithesis of someone making a request to exercise a right under European law.
Nevertheless, there are clearly some local commissioners who try to assess each case
solely on its merits. However, it is worrying that some if not all areas are not assessing
cases within an appropriate framework. Undue delay is not always focussed on the patient
but rather on current waiting times. There is some confusion as to whether funding should
be based on what the NHS would fund or what is funded by a PCT. There is at least one
Section 10
81
case where the decision is based in part on whether the budget for non-contracted services
has been exhausted in that financial year. The exceptional panel system also means that
decisions can take a substantial amount of time to reach, in large part to establish whether a
particular request reflects the patient pathway in a particular local area.
Evidence from the E112 analysis, case studies and commissioners’ survey also shows a
disparity in the type of claims that will be considered. For example, some commissioners
view a patient wanting to be close to their families during treatment to be an acceptable
reason to fund treatment abroad whereas in other areas this would not influence the decision
with the focus solely on clinical need.
Taking all of the above into account, the access a patient has to treatment in the EU is more
greatly influenced by where they live in the UK rather than their own specific healthcare
needs and choices.
There are potentially serious legal implications for failing to properly assess a patients’
request for planned healthcare within the EU, with the ECJ already criticising NHS
processes in this area. Given this, the evidence found that there are significant and
profound shortfalls and a postcode lottery in the quality and accuracy of NHS advice and
processes delivered locally to patients to access overseas treatment within the EU is of
serious concern to the Department of Health.
There is limited evidence that preparations are being made for the introduction of the new
directive and strong evidence that many local commissioners are not even aware that a new
directive is coming. Whilst the commissioners’ survey found that many PCTs and Health
Boards stated that they were looking at future demand for overseas care, this was not found
in the case studies. In any case, the examples given in the survey of activities to predict
future demand seemed to focus on looking at previous demand.
The current system of using panels to assess a request is in our opinion unsuitable should
numbers increase with the introduction of the new directive - which our research has not
discounted. Also, whilst it is understandable that local commissioners seek to establish
whether a patient pathway overseas exactly matches that locally, it is difficult to see how this
could be easily done with retrospective claims - a point recognised several of the case study
sites.
Concerns were raised continually during the case studies about governance issues arising
from allowing people to be treated abroad. This is an area where additional guidance may
be required, especially as under the new directive more patients may choose to go abroad
without seeking prior authorisation.
The clear message that is consistent throughout the research is that this is an area of
commissioning that PCTs find complex and challenging. This complexity has meant that
some PCTs are applying criteria by which they make decisions to fund that do not seem to
have any basis in current legislation or case law. The majority if not all PCTs see this as
Section 10
82
being a low priority area. Knowledge of processes and criteria for NHS funding of treatment
abroad does not appear widely known by staff within individual PCTs.
Given the complexity of the area, the difficulty commissioners have correctly interpreting
guidance and applying criteria and the potential consequences of failing to allow someone
treatment abroad when they had a clear right for funding under legislation and case law, it is
our opinion that this is an area of commissioning that would be more appropriately handled
nationally. This recommendation holds if numbers stay low or increase with the new
Directive. With low numbers it would seem a more efficient use of resources than to make
each local commissioner have their own set of processes to decide on requests. With higher
numbers, there is a higher likelihood that one decision will be challenged and found to be
incorrect.
Section 10
83
Bibliography
Bertinato L, Busse R, Fohy N, Helena Legido-Quigley H, McKee M, Palm W, Passarani I,
Ronfini F. Policy Brief: Cross-Border Health Care in Europe. October 2005.
http://www.euro.who.int/__data/assets/pdf_file/0006/108960/E87922.pdf
Botten G, Grepperud S, Nerland SM. Trading Patients Lessons from Scandinavia. 2 July
2003. http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B6V8X-4BSVGJF-22&_cdi=5882&_user=126317&_pii=S0168851003002586&_orig=search&_coverDate=09%2
F30%2F2004&_sk=999309996&view=c&wchp=dGLbVzzzSkWA&md5=a6a6693a3826bc9b52a4e89f0e21c91b&ie=/sdarticle.pdf
British Medical Association. House of Lords EU Committee Inquiry on Cross Border
Healthcare. November 2008.
http://www.bma.org.uk/healthcare_policy/responses_consultations/HoLEUCommInqrossbord
er.jsp
Burge P, Devlin N, Appleby J, Gallo F, Nason E, Ling T. Understanding Patients’ Choices at
the Point of Referral. 2006.
http://www.rand.org/pubs/technical_reports/2006/RAND_TR359.pdf
Connell J. Tourism Management. Medical Tourism: Sea, Sun, Sand and..... Surgery. 2006.
http://www.ataland.com/Files/Articles/z4.pdf
Coucher S (2002) The legal framework in relation to patient mobility Common Market Law
Review
Dawson D, Lowson KV. Reducing National Barriers to Cross-Border Health Care in Europe:
The English Experience. August 2001.
Department of Health. Consultant on the European Commission’s Proposals for a Directive
on the Application of Patients’ Rights in Cross-Border Healthcare. October 2008.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_0
89033.pdf
Department of Health. Impact Assessment of European Commission’s Proposal for
Legislation on Patients’ Rights in Cross-Border Healthcare. October 2008.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_0
89032.pdf
Department of Health. The European Commission’s Proposals for a Directive on the
Application of Patients’ Rights in Cross-Border Healthcare. April 2009.
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_0
98387.pdf
EurActiv.com. EU Countries to Discuss Cross-Border Health Plans. 5 June 2009.
www.euractiv.com/en/health/eu-countries-discuss-cross-border-health-plans/article-182897
EurActiv.com. Patient Mobility. 17 November 2005. www.euractiv.com/en/health/patientmobility/article-148956?_print
Europe for Patients. Europe for Patients Fact Sheet: The Future for Patients in Europe.
February 2004 – January 2007. www.europe4patients.org
Europe for Patients. Europe for Patients Final Conference: Benefits and Challenges of
Enhanced Patient Mobility.
www.iese.edu/en/events/projects/health/objectives/objectives.asp
European Commission. Cross-Border Health Services in the EU. Analytical Report.
May/June 2007. http://ec.europa.eu/health-eu/doc/crossbordereurobaro_en.pdf
Exworthy M, Kanavos P, Khonedoker F. Cross-Border Patient Flows for Health Care in
Europe: A Feasibility Study. December 2001.
Fotaki M, Boyd A, Smith L, McDonald R, Roland M, Sheaff R, Edwards A, Elwyn G. Patient
Choice and the Organisation and Delivery of Health Services: Scoping Review. December
2005. http://www.sdo.nihr.ac.uk/files/project/80-final-report.pdf
84
Glinos IA, Baeten R. Europe for Patients. A Literature Review of Cross-Border Patient
Mobility in the European Union. September 2009.
http://www.ose.be/files/publication/health/WP12_lit_review_final.pdf
Government Response to the House of Lords European Union Committee Report:
Healthcare across EU Borders: A Safe Framework. April 2009.
http://www.publications.parliament.uk/pa/ld200809/ldselect/ldeucom/30/9780104014356.pdf
Groene O, Poletti P, Vallejo P, Cucic C, Klazinga N, Sunol R. Quality Requirements for
Cross-Border Care in Europe: A Qualitative Study of Patients’, Professionals’ and
Healthcare Financiers’ Views. 2009. http://qshc.bmj.com/content/18/Suppl_1/i15.full.pdf
Horowitz MD, Rosenweig JA, Jones CA. Medical Tourism: Globalization of the Healthcare
Marketplace: Introduction. November 2007.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2234298/
International Medical Travel Journal. United Kingdom: Lords EU Committee Publishes
Healthcare Report. www.imtjonline.com/news/?entryid82=129719
Leggat P. Travel Medicine and Infectious Disease. Dental Health, “Dental Tourism” and
Travellers. January 2009.
http://www.sciencedirect.com/science?_ob=MImg&_imagekey=B7578-4VY16D3-11&_cdi=12892&_user=126317&_pii=S1477893909000337&_orig=search&_coverDate=05%
2F31%2F2009&_sk=999929996&view=c&wchp=dGLzVtzzSkWA&md5=7d223df63468b0cafb8c65c7d7cdb685&ie=/sdarticle.pdf
Legido-Quigley H, Glinos I, Baeten R, McKee M. British Medical Journal. Analysis: Patient
Mobility in the European Union. 27 January 2007.
http://www.bmj.com/cgi/reprint/334/7586/188
McHale JV. Medical Law Review. 2007. Case Comment: Rights to Medical Treatment in
EU Law. http://medlaw.oxfordjournals.org/cgi/pdf_extract/15/1/99
McKee M, Belcher P. British Medical Journal. Cross Border Health Care in Europe. 19 July
2008. http://www.bmj.com/cgi/content/full/337/jul03_1/a610
Medical Tourism Survey 2007. http://www.treatmentabroad.com/medical-tourism/medicaltourism-survey/
Medical tourist survey: 2008 report. http://www.treatmentabroad.com/medicaltourism/medical-tourist-research/
NHS European Office. What Do EU Competition Rules Mean for the NHS? June 2009.
http://www.nhsconfed.org/Publications/Documents/Euro_Briefing_4_final.pdf
Rosenmoller M, McKee M, Baeten R, Glinos IA. Patient Mobility: The Context and Issues.
http://test.cp.euro.who.int/Document/Obs/Patient_Mobility_ch1.pdf
Rosenmoller M, McKee Martin, Baeten R. Patient Mobility in the European Union: Learning
from Experience. www.europe4patients.org
Sellars C. World Hospitals and Health Services. Cross Border Access to Healthcare
Services within the European Union. http://www.mwe.com/info/pubs/sellars.pdf
Smith PC, Forgione DA. Global Outsourcing of Healthcare: A Medical Tourism Decision
Model. 7 February 2008. http://business.utsa.edu/wps/acc/0033ACC-205-2008.pdf
Treatment Abroad. Guide to Medical Tourism. www.treatmentabroad.net
Vallejo P, Sunol R, Van Beek B, Lombarts MJMH, Bruneau C, Vicek F. Volume and
Diagnosis: An Approach to Cross-Border Care in Eight European Countries. 2009.
http://qshc.bmj.com/content/18/Suppl_1/i8.full.pdf
Watson R. British Medical Journal. EU Strengthens Requirement for Patients to get Prior
Approval before being Treated Abroad. 11 April 2009.
http://www.bmj.com/cgi/content/full/338/apr03_1/b1400
Watson R. British Medical Journal. Reality of Cross-Border Health Care in Europe Draws
Closer. 11 April 2009. http://www.bmj.com/cgi/section_pdf/338/apr07_1/b1454.pdf (page 2
of 7)
What Happened to those 2008 Medical Tourism Forecasts?
http://www.imtjonline.com/articles/2009/what-happened-to-those-2008-medical-tourismforecasts-30002/
i
York D. Journal of Continuing Education in the Health Professions. Medical Tourism: The
Trend toward Outsourcing Medical Procedures to Foreign Countries. 2008.
http://www3.interscience.wiley.com/cgi-bin/fulltext/119815380/PDFSTART
i
Appendix A
Detailed costs of E112s
Condition
Cost (if
provided)
5000
14445
Treatment
Follow up consultation
30 day neuro-rehabilitation programme
Cancer
Very severe epilepsy
Gall bladder thickening and gall
stones
Cholecysectomy
2500
Severe epilepsy with complex partial
and secondary generalised seizures
EEG telemetry and 2 SPECT scans
Heart transplant
Annual check up
4000
5000
Cancer
Orthopaedic
6 month follow up to include CT scans, blood
tests and urine tests
Knee replacement
5000
15000
Neurodenocrine pancreatic tumours
Tests relating to neurodenocrine pancreatic
tumours
5000
Follow up treatment, surgery and medication
relating to a Koch Pouch
15000
Blood
tests,
endoscopy,
appointment
Casting, fitting of callipers
28000
5000
Cancer
Orthotic requirements
Episodic
symptomatic
fibrillation
consultant
atrial
Atrial Fibrillation
5000
Gender realignment
Adjustment to erectile and testicular prosthesis
Plastic surgery
Inpatient appointment - surgery
Hemi-sacroagenisis with hem pelvic
retroversion and previous failed
procedures
Second stage of Pelvic reconstruction
Multi focal epilepsy
Gamma knife treatment
Pain following surgery on broken Surgery to foot and heel, physiotherapy,
foot and heel
handling of scar and dressing.
Removal of an Ilzarov Method
Chondrosarcoma at the base of the
skull
Proton radiotherapy
Ureothrotomy/ureothroplasty
stricture
Knee surgery
Proton therapy
Neurosurgery
Breast cancer treatment
Gender realignment
Chordoma of the clivus
Breast cancer
Y
O R
K
Health Economics
C
O N S
O R T I U
M
for
2215
9000
15000
6064
3613
15000
28000
urethral
50000
9000
28000
15000
15000
Vein of galen malformation with
marcocephaly
Endovascular embolisation
6000
Removal of metalwork in tibia and radius
Fracture of tibia and radius
following operation in 2007
Epilepsy
Ictal SPECT procedure
Embryonal
Rhabdomyosarcoma
pelvis/vagina
Brachytherapy
Assessment. Exentoration. Removal of tumour
mass, sacrum, prostate, seminal vesicles and
possible removal of urinary bladder. Intraoperative radiotherapy
Low rectal adenocarcinoma
Hereditary
haemorrhagic
telangiectasia causing TIAs and
cerebral AVMs
Anaesthetist consultation prior to embolisation
Lymphoma
Treatment of lymphoma
Multiple spinal osteotomies
Stage III B nodular sclerosing
Hodgkin's disease
Acute gender dysmorphia
Feeding tube dependency
Heart disease
Primary malignancy of the brain
Chemotherapy
Phalloplasty and a Glansplasty
Tube weaning
All treatment relating to heart transplant
Consultation
15000
4000
28000
24000
5000
28000
50000
28000
50000
8650
44000
5000
Cleft Lip and palette, right facial
nerve palsy, right hypoplastic left Any treatment relating to feeding and breathing
ear, possible CHARGE syndrome
difficulties
16500
Breast cancer leading to Hodgkin’s Specific care relating to cancer and palliative
Disease
end of life care
28000
Pudendal neuralgia
15000
Surgical decompression of the pudential nerve
Severe intractable MR negative
frontal lobe epilepsy
Ictal SPECT scan
Advanced degeneration of hip
Short stem total hip replacement
Intractable epilepsy
Ictal SPECT scan
Therapeutic appliances
Crohn's Disease
Laparotomy and revision of Koch pouch
Bilateral sporadic retinoblastoma
Treatment relating
retinoblastoma
to
Bilateral
sporadic
Programme for the prevention and treatment
of tube dependency in infancy and early
childhood
Surgery
Tube feeding dependency
Malignant large b-cell non Hodgkin’s
lymphoma
Chemotherapy
Osteoarthritic
left
Tricompartmental OA.
4500
15000
4500
394
50000
1543
50000
28000
6253
knee.
Total knee replacement with titanium
Extensive
acute
intracranial
haemorrhage following RTA in UK
Nuerorehabilitation
10000
5000
i
Very severe refractory focal epilepsy
Long term feeding tube dependency
Cancer
excised
4000
15038
28000
Ankle surgery - Retinaculum reconstruction,
relocation and debridement of peroneal
tendons
5000
Albizzia nail lengthening and preoperative
investigations
Simulation for proton treatment
21451
28000
malignant Surgery - excision of scalp, reconstruction and
skin grafting
28000
Proximal femoral focal deficiency
Cancer
Incompletely
melanoma.
SPECT scan and inpatient management
Tube weaning at psychosomatic unit
Photon therapy
Clival chordoma
Breast cancer
Severe refractory epilepsy
Needs further treatment for residual treatment
Surgery and adjuvant treatments
SPECT plus inpatient care
28000
28000
4000
Colon cancer
Cancer
Scan and Capox chemotherapy.
resection.
Proton beam therapy
28000
28000
Llandau Kleffner (extreme epilepsy)
Magnetoencephalography (MEG) and MRI brain
scan under GA
Anterior
3000
£1,083,666
i